Most rejections fall into a few categories, and several are commonly overturned. None of these is legal advice; they are general principles for your grievance.
Pre-existing disease (non-disclosure)
Non-disclosure of a pre-existing disease is the single most common reason health claims are refused, and one of the most challengeable. To repudiate on this ground the insurer must show you knowingly withheld a material fact. A condition diagnosed after the policy began, or one you were genuinely unaware of, is not concealment. And once a health policy has run continuously for the IRDAI moratorium period (five years), it generally cannot be questioned for non-disclosure or misrepresentation at all, except for proven fraud. Ported policies carry forward the credit for the period already served.
Waiting period
Health policies carry waiting periods — an initial 30-day period, specific-disease periods, and a pre-existing-disease period. A rejection fails if the insurer applied the wrong waiting period, treated an unrelated ailment as the one under a specific-disease waiting period, or ignored the continuity credit you earned by continuously renewing (including on a ported policy). An illness that first arose after the applicable period ended cannot be shut out by it.
Policy exclusion / "not covered"
An exclusion must be explicitly stated and clearly disclosed, and it must actually apply to your treatment. Where the wording is ambiguous, the contra proferentem principle construes it against the insurer that drafted it. An insurer cannot apply an exclusion more broadly than its defined wording, apply one that was never clearly disclosed, or treat a covered treatment as excluded.
Cashless denied by the TPA
A cashless refusal by a third-party administrator (TPA) at the hospital desk is a preliminary, administrative decision — not a final rejection of your claim. You can still pay the hospital and file for reimbursement afterwards, and separately challenge the TPA's decision with the insurer's grievance cell. IRDAI's 2024 norms direct insurers to decide cashless requests quickly and extend cashless to all hospitals, so unjustified or slow cashless denials are themselves grievable.
Partial settlement / short payment (deductions)
A claim that is only partly paid is a dispute in its own right, and the Insurance Ombudsman expressly hears partial repudiations, not only outright rejections. A room-rent proportionate deduction is valid only when you took a room above your eligible category, so a policy with no room-rent cap gives no basis for one. Even then it cannot reach the cost of pharmacy and consumables, implants and medical devices, or diagnostics, and it cannot apply to ICU charges. Many "non-payable" items (housekeeping, admission kits, surgical consumables) are in fact subsumed into room, procedure, or treatment charges and cannot be billed separately. When a claim is disallowed in part, the insurer must give clause-wise reasons referenced to your policy, and a health claim cannot be repudiated at all without the insurer's Claims Review Committee. (These room-rent and item-list protections originated in IRDAI's 2020 circulars, folded into the 2024 Health Insurance Master Circular; they now operate through your policy wording — check its "associate medical expenses" and non-payable-items definitions.)
Delay in intimating the claim
Delay in intimating the insurer is not, by itself, a lawful ground to reject a genuine claim. The 2024 IRDAI Master Circular bars rejecting or closing a claim merely for delayed intimation — the insurer must show the delay actually prejudiced its ability to investigate. The Supreme Court has taken the same view: *Om Prakash v. Reliance General Insurance* (2017) held genuine claims should not be defeated on the technical ground of an explained delay, and *Gurshinder Singh v. Shriram General Insurance* (2020) held that where a theft was promptly reported to the police, delay in intimating the insurer is not fatal. Explain the reason for the delay in writing and prove the loss through independent records (FIR, hospital records).
Claim closed for want of documents
A "No Claim" closure for documents is procedural, not a finding on merits. Under the 2024 IRDAI Master Circular the insurer must call for the documents it needs at one go rather than in piecemeal instalments, cannot insist on documents it could obtain itself, and must give a reasonable opportunity before closing. Ask in writing for the claim to be reopened. Note that police documents — FIR, untraced report, fire-brigade report, post-mortem report — are listed among the papers the customer submits, and an FIR copy is given free to the informant, so supply those rather than withhold them.
Alleged fraud or an inflated claim
Fraud is never presumed — the burden of proving it is on the insurer, and the allegation must be specific: which document is fabricated, which bill inflated. A disagreement about how much a loss is worth is a quantum dispute, not dishonesty, and an innocent error is not fraud. For life insurance, Section 45 of the Insurance Act means a policy generally cannot be called in question on any ground, including fraud, after three years from issuance, reinstatement, or the rider date, whichever is later.
"Experimental" or unproven treatment
The exclusion only reaches treatment that genuinely lacks acceptance in mainstream practice — established standard of care is not an experiment, and the treating doctor's reasoned opinion is central evidence. IRDAI's exclusion-standardisation norms list specific modern treatment methods that must be covered rather than excluded as unproven, including robotic surgery, oral chemotherapy, immunotherapy in the form of monoclonal-antibody injections, deep-brain stimulation, and stem-cell therapy in the narrow sense of hematopoietic stem-cell transplants for haematological conditions. That list is precise — stem-cell treatments for other conditions are not on it and may still be validly excluded.
Congenital condition
Turns on the exact wording. Many policies exclude only external congenital anomalies (visible, accessible parts of the body) while internal congenital conditions are covered, often after a waiting period. The insurer must show the condition falls squarely within the clause; ambiguity is read against it. And a condition you never knew you had — internal, symptomless, first diagnosed after the policy began — was not concealed.
Policy lapse / premium default
Depends on the policy type and the dates. For life insurance, a death within the grace period (commonly 30 days; 15 for monthly modes) generally keeps the cover in force with the overdue premium deducted, and a policy validly revived before the event is in force — an insurer that accepted the revival premium cannot simply treat the policy as dead. For health insurance, renewing within the grace period preserves continuity and waiting-period credit, though cover for an event during an unpaid break depends on the policy's terms. Check whether a payment actually failed or was merely misapplied.
Underinsurance / the average clause
In fire and property insurance the condition of average scales the payout down in proportion to underinsurance. It is lawful only where the sum insured was genuinely below the value at risk, measured on the basis the policy prescribes (reinstatement value versus market value less depreciation are very different numbers), and correctly computed. Land value is not part of buildings cover. Many policies waive average where the shortfall is within a stated margin. The average clause does not apply to health insurance.
Contribution / holding more than one policy
Contribution applies only between indemnity policies covering the same risk. A fixed-benefit policy — personal accident, hospital cash, benefit critical illness, life — pays in full regardless of any other cover. Between two indemnity health policies, IRDAI's norms let the policyholder choose which insurer to claim from; that insurer must settle up to its own sum insured, and any balance above that limit can be claimed from the second insurer.
Portability / continuity credit denied
On porting, the new insurer must carry forward the waiting-period and pre-existing-disease credit already earned, to the extent of the previous sum insured plus accrued bonus. Waiting periods do not restart on a port; only an enhanced portion of cover serves fresh periods. The porting process itself transfers the claims and cover history between insurers, so the new insurer accepted the policy knowing it.
Personal accident: "that was not an accident"
An accident is an unexpected, unintended injury by external and visible means, read from the insured person's standpoint. It is for the claimant to first show the death or injury falls within the accident cover (FIR, post-mortem, medical evidence of the external trigger); once that is done, an insurer invoking an exclusion must prove it. *Rita Devi v. New India Assurance* (2000) held a murder can be accidental death where the dominant intention of the act was something else (stealing the victim's autorickshaw) and the killing was incidental. Where the policy requires the injury to operate "solely and directly and independently of all other causes", a contributing medical condition is contested ground — document the chain from the external event.
Alleged commercial use of a private vehicle (motor)
A limitation-as-to-use breach does not automatically defeat a claim. The insurer must prove the vehicle was actually being used for hire or reward, and the breach must bear on the loss. In *National Insurance v. Nitin Khandelwal* (2008) the vehicle was allegedly on a taxi trip when it was stolen; the Supreme Court held the breach was not germane to the theft and upheld settlement on a non-standard basis at 75% of the claim, an approach applied again in *Amalendu Sahoo v. Oriental Insurance* (2010). Even a proven breach often reduces rather than extinguishes the claim.
What to do for any rejection
Get the written repudiation letter with the exact clause, gather the documents that answer that specific reason, and raise a written grievance with the insurer's Grievance Redressal Officer — then escalate up the ladder (IRDAI Bima Bharosa → Insurance Ombudsman) if it is not resolved.
Source: IRDAI health-insurance regulations and Master Circular, 2024; established principles of insurance-contract interpretation. Last reviewed 2026-07-25.