Being denied a health insurance claim due to lack of documentation can be frustrating, but recent guidelines from the Insurance Regulatory and Development Authority of India (IRDAI) aim to address the issue. These revised rules focus on ensuring transparency, simplifying documentation, and protecting planholders from unfair practices.
Highlights of the IRDAI guidelines
1. No Claim Rejection for Lack of Documents
Insurers are prohibited from denying or closing for insufficient documentation or late notice if the material facts of the case are clear
2. Simplified documentation
Insurers must provide a standardised review of documentation requirements at the time the policy is issued. Only important documents directly relevant to the case may be requested.
3. Written explanation of rejections
If the claim is denied, insurers must provide a detailed written explanation explaining the reasons. Proper policyholders should review this document to ensure that the disclaimer meets the terms of their policy.
4. Assistance with mail
Insurance companies must help claimants identify missing documents and resolve discrepancies in order to process claims.
General documentation required for claims
- • Hospital charges and discharge summary
- • Physician prescriptions and medical records
- • Investigation reports (e.g. x-rays, blood tests) .
- • Policy copy and completed claim form
- • Loss assessment reports
- • Repair or replacement of expenses or receipts
Steps for handling complaints
1. Contact the Insurer's grievance redressal mechanism
Submit a formal complaint and ensure you receive an acknowledgement. Insurers must resolve grievances within 15 days.
2. Reach out to Irdai’s Bima Bharosa platform
If dissatisfied with the insurer’s response, escalate your complaint to Irdai’s grievance platform for additional support.
3. Approach the insurance ombudsman
For impartial resolution, escalate unresolved issues to the Insurance Ombudsman, which provides a fair and independent review of disputes.
With these measures in place, policyholders can expect a more transparent and fair claims process. Staying informed about your rights and the latest guidelines can help you navigate insurance claim disputes more effectively.
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