Insurance claim rejected India — grievance to insurer, Bima Bharosa, Insurance Ombudsman (₹50 lakh, 1 year), consumer commission (2026)
Step-by-step map when a health, life, motor or other personal insurance claim in India is rejected, partly paid or delayed: read the repudiation letter, file a written grievance with the insurer (IRDAI expects resolution within 14 days), escalate on IRDAI’s Bima Bharosa portal, and approach the Insurance Ombudsman under the Insurance Ombudsman Rules, 2017 — free, no lawyer needed, within one year, for claims up to ₹50 lakh — or a consumer commission instead. Educational only — not legal advice; Adhiwakta does not file insurance complaints or deal with insurers.
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Step 1 — read the rejection letter against the policy
Insurers must give reasons for repudiation. Match each reason with the exact clause in your policy wording and schedule: waiting periods, exclusions, pre-existing disease definitions, sub-limits, room-rent caps, late intimation, missing documents, or alleged non-disclosure. Many disputes turn on wording. Ask in writing for the claim file, investigation report or doctor’s opinion relied upon if it is not shared.
Step 2 — written grievance to the insurer (14-day resolution)
Write to the insurer’s grievance redressal officer (GRO) — by email or the insurer’s grievance portal — quoting the policy and claim numbers, why the rejection is wrong, and the relief you want. Under IRDAI’s 2024 master circular on protection of policyholders’ interests, the insurer must acknowledge the complaint immediately and give its resolution within 14 days, with reasons and reference to the policy terms if it does not accept the complaint. Keep the acknowledgement and complaint number.
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Write in Hindi or English · general guidance, not legal advice
Step 3 — Bima Bharosa (IRDAI)
If the insurer does not respond or you are unhappy, you can register or escalate the grievance on IRDAI’s Bima Bharosa system (bimabharosa.irdai.gov.in) or through the IRDAI grievance call centre (155255 / 1800 4254 732). IRDAI monitors the insurer’s handling; it is not a court and does not itself decide your claim amount, so keep the Ombudsman or consumer-commission timeline in mind.
Step 4 — Insurance Ombudsman (free, no lawyer needed)
Under Rule 14 of the Insurance Ombudsman Rules, 2017 you can complain to the Ombudsman after making a written representation to the insurer, if the insurer rejected it, did not reply within one month, or you are not satisfied with the reply. The complaint must be made within one year of the rejection / unsatisfactory reply (or of expiry of that one month); delay can be condoned in suitable cases. The Ombudsman can entertain claims where the compensation does not exceed ₹50 lakh including expenses (raised from ₹30 lakh by the 2023 amendment). There is no fee, the Rules do not provide for engaging a lawyer, complaints can be filed online at cioins.co.in or at the office (17 offices) covering the insurer’s branch or your residence, and the Ombudsman passes an award within 3 months of receiving all requirements (or a recommendation within 1 month if both sides agree to mediation). The award binds the insurer; if you are not satisfied you may still use other legal remedies.
Ombudsman or consumer commission?
The Ombudsman cannot take up a matter already pending before, or decided by, a court, consumer commission or arbitrator on the same subject. Alternatively, a consumer complaint for deficiency in service can be filed under the Consumer Protection Act, 2019 (online on e-Jagriti), generally within two years of the cause of action (s.69). Third-party motor injury or death claims go to the Motor Accident Claims Tribunal, not the Ombudsman. Choose one primary forum deliberately — the Ombudsman is free and faster; a commission can award compensation and costs but takes longer.
Health insurance — rules worth knowing
IRDAI’s 2024 master circular on health insurance says insurers must decide cashless authorisation requests within one hour and give final discharge authorisation within three hours of the hospital’s request; if delay beyond three hours causes extra hospital charges, the insurer bears them. After the moratorium period — 60 months of continuous coverage (portability and migration credits count) — a health policy or claim cannot be contested for non-disclosure or misrepresentation except for established fraud. Check your policy start date and portability history before accepting a ‘non-disclosure’ rejection.
Life insurance — the three-year rule
Section 45 of the Insurance Act, 1938 (as amended in 2015) says a life insurance policy cannot be called in question on any ground after three years from the date of the policy, risk commencement, revival or rider, whichever is later; within those three years the insurer can repudiate for fraud or material mis-statement only on the grounds and with the reasons the section requires. Nominees should keep the death certificate, policy bond, medical records and the insurer’s letters together.
Papers to gather
Policy document with schedule and wording; premium receipts; claim form and claim number; rejection / partial-settlement letter; hospital bills, discharge summary, prescriptions and reports (health); FIR, survey report and repair estimates (motor); death certificate and medical records (life); all emails and grievance numbers; and a chronology of dates. Never alter medical records or bills.
What this guide is not
It is not a promise that any claim will be paid, not an interpretation of your specific policy, and not advice on accepting a partial settlement. IRDAI circulars and Ombudsman rules change — check the live versions on irdai.gov.in and cioins.co.in.
How Adhiwakta can help
We do not file Ombudsman or consumer complaints, or negotiate with insurers or TPAs. Adhiwakta is a facilitation platform, not a law firm. We do not file cases, appear before any authority, or promise any result. Use Ask Adhiwakta to describe your situation for general guidance from an independent advocate, or start with the AI helper to organise your facts and papers. Educational only — not formal legal advice.
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Frequently asked questions
- My insurance claim was rejected. What is the first step?
- Read the reasons against your policy wording, then send a written grievance to the insurer’s grievance officer. IRDAI expects insurers to resolve complaints within 14 days. If unresolved, escalate on Bima Bharosa and then approach the Insurance Ombudsman or a consumer commission.
- What is the time limit to approach the Insurance Ombudsman?
- Within one year of the insurer’s rejection or unsatisfactory reply, or of the expiry of one month after your written complaint if the insurer did not reply (Rule 14, Insurance Ombudsman Rules, 2017). The Ombudsman may condone delay in suitable cases.
- Is there a fee or a limit for Ombudsman complaints?
- There is no fee and no lawyer is needed. The Ombudsman can deal with claims where the compensation does not exceed ₹50 lakh including expenses. Complaints can be filed online at cioins.co.in.
- Can I go to the consumer court instead?
- Yes, a consumer complaint for deficiency in service is an alternative (generally within two years). But the Ombudsman will not take a matter already pending before or decided by a court, consumer commission or arbitrator on the same subject.
- Does Adhiwakta file insurance complaints?
- No. We do not file complaints or deal with insurers or TPAs. Use Ask Adhiwakta or the AI helper for general educational guidance only.
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