Your health insurance claim has been rejected
What a repudiation letter actually says, what to check in it, and how to reply in a way that is factual and complete.
What this situation means
A rejection — often called a repudiation — means the insurer has decided not to pay the claim, and the letter or email should say on what ground. That ground is the whole of the dispute. Everything you do next turns on reading it precisely.
Common grounds include a waiting period that had not expired, a condition the insurer says was pre-existing, something the insurer says was not disclosed when the policy was taken, a specific exclusion in the policy wording, or a view that the hospitalisation was not medically necessary. Two letters can use similar language and still rely on completely different clauses.
A rejection is not automatically wrong, and it is not automatically right either. Some claims genuinely fall outside what the policy covers. The useful first step is to find out exactly what was decided and why, rather than to assume either way.
What to check first
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The exact ground stated
Read the letter slowly and write the ground down in one sentence. If more than one ground is given, number them — a reply has to answer each.
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The clause relied upon
Most rejections cite a clause or condition. Find that clause in your policy wording and read it in full, not just the part quoted.
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Whether the facts match
Compare the ground against your own records. Dates of first symptoms, dates of diagnosis, the date the policy began and the date of admission often decide these questions.
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What the insurer relied on
If the letter refers to a document, a medical opinion or an investigation, note it. You are entitled to ask, in writing, what it was based on.
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Whether any query went unanswered
Sometimes a rejection follows a query that was answered partly, or not at all. Check your own sent folder before assuming.
What to keep
- The rejection or repudiation letter, with the date it was issued and the date you received it
- The policy schedule and the full policy wording for the year of the claim
- The complete email thread with the insurer or TPA, with attachments
- The discharge summary, the itemised final bill and the investigation reports
- Any earlier prescriptions or reports relevant to when the condition began
- A one-page timeline of dates: first symptoms, consultation, admission, discharge, claim, decision
How to write to your insurer
- Reply on the same email thread, with the claim number in the subject line, so the whole history stays in one place.
- Answer each ground separately and in the same order the insurer raised it. A partial reply usually produces another round of correspondence.
- State a fact, then name the document that shows it, and attach that document. Facts your own papers support are worth far more than adjectives.
- If you believe the clause does not apply on these facts, say precisely that, and say why. There is no need to dispute the policy terms themselves.
- Ask for the decision to be reviewed and conveyed in writing, and ask for an acknowledgement of your representation.
A written record helps you keep track of what was asked, what you submitted and what was communicated. The claim guide has the email templates.
How ClaimSaathi can help
We can help you read the rejection letter, locate the clause relied upon, work out what the insurer is actually saying, and prepare a representation that answers each ground with the documents you hold. Where the honest reading is that the insurer's ground is correct, we will tell you that rather than encourage a long dispute.
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