Health insurance claims: How to ensure fair grievance redressal | Mint

My health insurance company has rejected my claim because I am unable to furnish internal hospital papers. I have submitted all the required documents. What are my options to ensure that my grievance is addressed fairly?

—Name withheld on request

If your insurance claim has been rejected due to lack of documentation, it’s essential to understand your rights under the latest guidelines from the Insurance Regulatory and Development Authority of India (Irdai). These guidelines emphasize transparency, ease of documentation, and policyholder protection, ensuring fair treatment in claim processing. There is also a mention that no claim shall be rejected or closed for want of documents or for delayed intimation.

Insurers are mandated to provide a written explanation for claim rejections. Carefully examine this document to understand the reasons and whether it aligns with your policy terms. This clarity will help you make the necessary corrections.

The 2024 Irdai guidelines aim to simplify documentation requirements, ensuring policyholders are not burdened with unnecessary paperwork. Insurers are required to demand only essential documents directly relevant to the claim. Standardized checklists must be provided at the time of policy issuance.

Insurers must assist policyholders in identifying missing documents and guide them to ensure claims can be processed without delay. Insurers cannot reject a claim solely for minor document-related discrepancies if the material facts of the claim are established.

Common documents needed: (i) Hospital bills and discharge summaries; (ii) Doctor’s prescription and treatment records; (iii) Investigation reports (e.g., X-rays, blood tests, etc.); (iv) Claim form and policy copy; (v) Loss-assessment report; and (vi) Bills or receipts for property repairs or replacement.

Submit a formal complaint through the insurer’s grievance redressal mechanism. Insurers must resolve grievances within 15 days. Ensure you receive an acknowledgement of your complaint for tracking.

You can also contact the Irdai Bima Bharosa site in case you are not happy with the grievance redressal officer’s response.

If unresolved, escalate to the Insurance Ombudsman for impartial resolution.

Shilpa Arora is co-founder and chief operating officer at Insurance Samadhan.