How to Escalate If your health claims gets rejected?

Methods to Get your Claims Paid

Getting your insurance claim is one of the most important services that your insurance provider must offer you. If in any case, your claim is rejected because of a wrong information inserted at the time of agreeing to the policy or a mistake from the part of the insurance agent then you as the insured have every right to escalate the problem to the insurance company and fight for your claims.

Why your claim was rejected?

You apply for claim in the hope that it will be processed soon and you will get your money, but to your dismay you may find the claim rejected. Here are some reasons as to why a claim gets rejected.

• Incorrect or wrong information – Giving any faulty or wrong information in your policy can affect your claim to be rejected. Always review your agreement policy before signing to make sure you have included accurate and trusted information.
• Your coverage – Always check your policy thoroughly and make sure what your insurance covers, if you are applying for something which is not included in the coverage then your claim will be rejected.

Check your policy documents

Check your insurance policy and claim form, if the name and number is accurate as well as you applied for the coverage as listed in the policy along with all other details you entered in the agreement, reports, files, documents, certificates, consultation fees, bills, summary, receipts etc. If there is a single error, it can lead to your claim rejection hence contact your insurance provider to make the relevant changes if any.

Contacting the insurance company

Once you have reviewed your policy and made sure that there are no mistakes from your part, then you can formally write a complaint to the insurance company stating your grievance redressal for claim rejection or call and speak to their complaint handling representative.

File an appeal

If the insurance company does not heed your words and still refuses to pay the claim, you have every right to file an appeal with your insurer, who will be called for an internal review to submit their decision and supporting documents on the case.

Get independent assessment

Contact a third party who is a loss assessor or loss adjuster to look into the whole scenario where you and the insurance provider is involved. He will look into the situation unbiased and send a report to the insurance company which will be considered as evidence and also charge you a fee for the same.

Seek the help of Ombudsman

The financial ombudsman offers independent and free service, investigating the complaint you raised against the financial institution. They will hear both sides of the story, cross check the documents and come to a fair conclusion. If they find right on your side then the insurance company will be called to explain their action, apologise and pay compensation.

IRDA Links and Guidelines

• If you have grievance, approach the grievance cell of the Insurance Company first.
• If you are not happy with their solution, you can escalate the matter to IRDA
• How to make a complaint?
• Complaint Logging at IRDA
• Integrated Grievance Management System – By IRDA
• IRDA – Updated list of Life Insurers
• IRDA – Updated list of Non-Life Insurers