My neighbour recently was hospitalised and has been detected with some kidney infection. But, the insurer rejected his claim. I am worried if my insurer will also reject the claim. What should I do in such a case?
Amit Arora, Mohali
Normally health insurance claims are rejected because of the claims process being incomplete or inadequate, the claim being part of the exclusions in the policy contract or withholding facts at the time of taking the policy, which is the cause of the claim. However, just because someone’s insurance claim was rejected does not mean that you should worry about your insurer not clearing your claims when such a situation arises. In case you do face such a scenario, do not worry too much as you have a few options to explore. First, you should check with the insurer on the grounds for the claim to be rejected. Normally every insurer has a grievance redressal cell, which you should interact with immediately. And, do make a written complaint with a copy of receipt from the insurer so that you have proof that your complaint was registered and recorded.
If you do not hear from the insurer on the course of action on your complaint within two weeks of your submission of the complaint (some insurers may have a 15 day or 30 day policy on grievance redress), you can approach the Grievance Redressal Cell of the Consumer Affairs Department of the insurance regulator – IRDAI. Once they get it, they have stipulated procedures for addressing complaints and would seek a response from the insurer. If you do not find any satisfactory response even after taking this step, you should seek assistance from the insurance ombudsman or consumer courts. Under any circumstances, do maintain the paperwork that you are engaged when corresponding with the insurer, ombudsman and the grievance cell of IRDAI. Make sure the reason for claim rejection is the focus, with all the necessary facts from your end.
