Claim Cut Or Stuck? Here’s How To Fight An Insurance Dispute

A claim that is delayed, partly paid, or rejected can leave policyholders unsure what to do next. The first step is to get the insurer’s decision in writing, check it against the policy, and keep a record of every complaint and reply.

Get The Insurer’s Reasons In Writing

“Don’t rely on a verbal explanation. Ask the insurer for the written reason for rejection or deduction, the relevant policy clause, and a detailed claim settlement statement,” says Shilpa Arora, co-founder and chief operating officer, Insurance Samadhan.

For a delayed claim, ask what is pending and whether the insurer needs more information or documents. If only part of the claim is paid, request a breakup of the deductions. If the claim is denied, ask which policy clause the insurer relied on and what information or documents it used to reach its decision.

“If only part of your claim is paid, ask for a clear breakup of every deduction. If the deductions look incorrect, ask the insurer to explain in writing and share the relevant policy terms and conditions,” says Aayush Dubey, co-founder and head of research, Beshak.org.

Keep the policy document, claim form, bills, medical records, claim number, and all correspondence in one place. For a hospital bill, compare each deduction with the policy terms and ask the insurer to explain any amount that is unclear. A written response also gives you something specific to refer to in a complaint.

Start with a written complaint to the insurer’s grievance redressal officer (GRO) and save the acknowledgement. The Insurance Regulatory and Development Authority of India (Irdai) says insurers should resolve complaints within 15 days. If you remain dissatisfied or the complaint is unresolved, you can raise it through Irdai’s Bima Bharosa portal: bimabharosa.irdai.gov.in.

Escalate And Weigh The Cost Of Help

“If the issue is not resolved, it can be escalated to Irdai’s Bima Bharosa platform and then to the Insurance Ombudsman. The Ombudsman can take up eligible disputes where the compensation sought is up to Rs 50 lakh - provided the complaint was first raised with the insurer,” says Dubey.

The Insurance Ombudsman is an external grievance forum. The Council for Insurance Ombudsmen says a complaint may be considered if the insurer has not responded within 30 days or the policyholder is unhappy with its response. The complaint must generally be filed within one year of the insurer’s rejection, repudiation or partial settlement. The compensation sought, including expenses, should not exceed Rs 50 lakh. cioins.co.in is the website of the Council for Insurance Ombudsmen (CIO).

A policyholder can also consider approaching the Consumer Commission. Unlike the insurer’s grievance route, Bima Bharosa and the Ombudsman, filing a case with the commission involves a fee. The fee depends on the amount claimed and where the case is filed, says Dubey. A lawyer may be useful if the case is complex, the amount is significant or legal representation is needed.

“For a straightforward deduction, a written representation with supporting documents may be enough. But where a substantial claim is rejected over an exclusion, alleged non-disclosure or a disputed policy condition, expert assistance can help,” says Arora.

An insurance adviser may help check the insurer’s decision against the policy wording, review deductions or identify missing documents. For instance, if Rs 15,000 has been deducted as non-medical expenses, an adviser can help assess whether the deduction follows the policy terms.

The cost of professional help should be weighed against the amount in dispute, the strength of the case and the time involved. For smaller claims, policyholders can first make a clear written representation and use the available grievance channels.

“An insurance advisor can help you understand the insurer’s decision, check it against the policy terms, review deductions or documentation gaps, and guide you on the next steps,” says Dubey.

FAQs

What should I ask the insurer if my claim is delayed, partly paid, or rejected?
Ask for the reason in writing, the relevant policy clause, and, for a partial payment, a detailed breakup of deductions.

How can I escalate a claim dispute?
Complain in writing to the insurer’s grievance redressal officer and keep the acknowledgement. If unresolved, use Irdai’s Bima Bharosa portal or approach the Insurance Ombudsman, subject to eligibility and timelines.

When should I seek expert or legal help?
Consider it when the claim amount is substantial, the dispute involves a complex policy clause, or the insurer’s decision remains unresolved. Weigh the likely cost against the amount at stake.