Not an HMSThe revenue layer above the one you already run — orchestration for hospitals, health aggregation for employers.See the difference →
Sign inGo to my accountStart freeGo to my account
Booking page For doctors For hospitals Corporate health Health packages Labs Pharmacy Nadi Compare Free tools Referrals Claim help

If your claim was rejected

The letter tells you the ground. It does not tell you what happens next.

Rejection letters are written in the insurer’s language, not yours. One sentence names a reason — proportionate deduction, pre-existing, not medically necessary — and the rest is process you are expected to already understand.

HELP · DRAPTO
● Answer on this page
● Jargon translated
● Steps numbered
✓ written for 11pm, not the demo
You referFrom the directory, in one tap
They answerNo account needed. A link in their inbox
You find outWhat happened to your patient, rather than wondering

There is a defined escalation process in India. It has deadlines, it costs nothing to start, and it does not need a lawyer. This page explains the ground you were given and the route that exists after it. It cannot tell you whether your claim will succeed, and anyone who says they can is guessing.

Start here

Paste the reason your letter gives. In whatever words it used.

Most people cannot name their ground — the letter rarely uses the word the industry uses. Sahayak reads the sentence and tells you which ground it is, what it actually means, and what the process after it looks like.

Sahayak · claim informationRuns in your browser

Nothing you type is sent anywhere — it runs in your browser and reaches no server. Sahayak explains grounds and process. It cannot assess your claim or predict an outcome.

The clock, not the claim

A query window closes whether or not anybody opened the letter.

Most payers allow a fixed period to respond to a query. Miss it and the claim is closed — not rejected on merit, just closed.

Claims queried in a month 38
Typical window to respond 7 days
Answered inside the window 31
Closed because nobody replied = 7
Average claim value × ₹46,000
Lost to a calendar ₹3,22,000

Illustrative. None of those seven were rejected on clinical grounds — they expired. That is the cheapest money in the building to stop losing, and it needs a countdown rather than a person remembering.

Before you write the appeal

Worth appealing, and not.

Most rejections fall into a few shapes, and only some of them move. Knowing which before you spend a week on it is most of the work.

Usually moves Documentation gap — the record exists, it was not attached Coding — a more specific code was available Rarely moves Policy exclusion Waiting period

Widths are illustrative of how often each is worth the effort, not of amounts. Every free guide here covers one of these shapes.

The first 48 hours

Four things worth doing before you argue with anybody.

None of these commits you to anything. All of them are harder to do later, once the hospital file is archived and the people who treated you have moved on.

Get the rejection in writing

A phone call is not a rejection. Ask for the written communication naming the ground and the policy clause it relies on. Everything downstream needs that document.

Ask the hospital for the full file

Discharge summary, indoor case papers, investigation reports, the itemised bill and the pre-authorisation correspondence. You are entitled to your own records.

Find your policy wording, not the brochure

The actual policy document, with the schedule showing your sum insured, room-rent limits and sub-limits. The clause the insurer cited will be in there.

Write down the dates

Admission, discharge, when the insurer was told, when documents were submitted, when the rejection came. Several grounds turn entirely on a date.

One caution. Do not sign anything describing a payment as full and final settlement until you understand what you are giving up. If money is being offered while you are still at the hospital and still unwell, it is reasonable to say you will look at it later.

The route that exists

Four rungs. You start at the first, and most of it is free.

This is the general process in India for a health insurance grievance. Your own policy document and the insurer’s letter will name the specific offices and time limits that apply to you, and those override anything summarised here.

  1. The insurer’s Grievance Redressal Officer Every insurer has one, and the contact details are in your policy document and on the insurer’s website. Put the complaint in writing, attach the rejection letter, and keep the acknowledgement. A response is generally due within 15 days.
  2. IRDAI — Bima Bharosa The regulator’s grievance portal, at bimabharosa.irdai.gov.in. This is the step for when the insurer does not respond, or responds without addressing the point. It creates a record the insurer has to answer.
  3. The Insurance Ombudsman An independent office set up under the Insurance Ombudsman Rules. It is free, you do not need a lawyer, and the award binds the insurer up to the limit prescribed in the rules. There is a time limit for approaching it, generally measured from the insurer’s final reply, so this is the rung where delay actually costs you something.
  4. Consumer commission If you choose to go further. This is slower and more formal, and unlike the Ombudsman it is a route people usually take with representation.

Check the specifics against a primary source. Time limits, monetary caps and jurisdiction change, and they differ by policy. IRDAI and the Council for Insurance Ombudsmen publish the current rules; your policy document governs your case. We have deliberately not printed figures here that we cannot keep current.

Find your ground

Fifteen reasons account for most rejections in India.

Each page explains how the ground is actually applied, what fact it turns on, the three things people most often get wrong about it, and what to check in your own documents. Two sections — the standard policy wording and what the Ombudsman has held — are still being compiled from published awards, and are marked as missing on each page rather than filled with something plausible.

Room rent cap and proportionate deductionThe room cost more than the policy allowed, so every associated charge was cut in the same ratio Pre-existing disease and non-disclosureThe insurer says the condition existed before the policy began, or was not declared Waiting period not completedThe policy was active, but not long enough for this particular condition Sub-limit on a procedure or conditionThe policy caps what it pays for this one thing, regardless of the sum insured Treatment excluded under the policyNot covered at all, rather than limited in what it pays Not medically necessaryThe insurer accepts the treatment happened but disputes that it needed admission Day-care procedure not coveredThe stay was under 24 hours and the procedure is not on the covered list Documentation incomplete or illegibleThe claim was never decided on its merits — something was missing or unreadable Delayed intimation to the insurerThe insurer was told later than the policy required Cashless denied, reimbursement requiredNot a rejection — the insurer would not settle directly with the hospital Policy lapsed or premium unpaidThe insurer says cover was not in force on the date of admission Exceeds the sum insuredThe claim is larger than the cover available for the year Consumables and non-medical itemsGloves, syringes, administrative charges and similar items disallowed Pre and post-hospitalisationCosts before or after the stay, outside the window the policy allows Outside the networkThe hospital was not on the insurer’s empanelled list

Free tools

Two calculators, for the two deductions people most often cannot check.

Proportionate deduction calculator

If your room breached the cap, the insurer does not just cut the room charge. It reduces surgeon fees, theatre, nursing and investigations in the same ratio. This shows you the arithmetic on your own numbers.

Room rent eligibility calculator

What room category your policy actually entitles you to, before you are admitted. This is the single cheapest thing to get right, and the most expensive to get wrong.

Who is telling you this

We are a software company, and we should say why this page exists.

Drapto builds revenue-integrity software for Indian hospitals. Our customers are the finance and billing teams on the other side of exactly these deductions — the ones trying to catch a room-rent breach at admission, while it is still fixable, rather than on a settlement advice three weeks later.

Which means we spend our working lives reading these grounds, and we know that the patient receives no explanation of any of it. That is the whole reason this section is here. It is not a lead magnet: there is nothing to buy on this page, and you are not a customer we have.

What we are not. Drapto is not an insurance advisor, broker or agent, and is not registered with IRDAI in any such capacity. Nothing here is advice on your specific claim, and we make no representation about the outcome of any claim. For advice on your policy, speak to your insurer or a licensed advisor.

You do not have to work this out alone.

Sahayak explains the grounds your insurer gave and the official escalation path. It is an information service, not an insurance advisor.

Check your rejectionThe ombudsman route