Most policyholders believe that the moment an insurance company rejects their claim, the next step is to immediately approach the Insurance Ombudsman. That is incorrect.

Whether it is Life Insurance, Health Insurance, Motor Insurance, Personal Accident Insurance or any other insurance policy, the re is a legal escalation process that must be followed before the Insurance Ombudsman can hear your case. Understanding this process can significantly improve your chances of obtaining a fair review of your claim.

Step 1 – Reply to the Insurance Company’s Decision

Suppose your insurance claim has been

·       Partially Paid
·       Rejected
·       Closed
·       Repudiated
·       Terminated

And you genuinely believe that all disclosures made by you during policy purchase were complete, honest and accurate. Do not remain silent. Reply to the same email from which the insurance company communicated its final decision. Your email should mention

·       You are not satisfied with the claim decision
·       You request the insurer to review your claim
·       Ask the insurer to explain

Which policy clause has been relied upon?
What evidence supports the decision?
Why has the claim been rejected or reduced?

Important – Never rely only on verbal assurances from

·       Agents
·       Brokers
·       Customer care executives

Always communicate through emails. Email creates

·       Timestamped evidence
·       Written communication
·       Documentary proof

This becomes extremely valuable if the dispute is later examined by the Insurance Ombudsman or a Court. Do not threaten the insurer by saying “I will approach the Insurance Ombudsman.” Simply ask for a detailed written review. A professional approach works better.

Step 2 – Escalate the Matter to Insurance Company’s Grievance Department

If the insurer maintains the same decision after reviewing your email, escalate the complaint to the insurer’s official Grievances Redressal Officer (GRO) or their grievance email address. Many policyholders skip this stage.

However, this step is extremely important because the Insurance Ombudsman expects that the insurer has first been given a reasonable opportunity to resolve the dispute internally. Generally, the ombudsman can be approached if

·       The insurer rejects your complaint
·       You are dissatisfied with the insurer’s reply
·       The insurer does not respond within one month of receiving your complaint

Step 3 – Understand the Time Limit

Once the insurer rejects your grievance or one month passes without a satisfactory response, you generally have up to one year to file your complaint before the Insurance Ombudsman. The Ombudsman scheme also requires that the complaint be within the applicable monetary jurisdiction, which does not exceed Rs 50 Lakh.

Although one year may sound life a long time, but do not wait. Insurance disputes become harder to manage as

·       Documents get misplaced
·       Memories fade
·       Evidence becomes difficult to collect

The earlier you file, the better.

Step 4 – Documentation

While submitting your complaint, keep the following details and documents ready,

·       Policy Schedule, Policy number, Customer Id,
·       Proposal form (If shared by the Insurer)
·       Claim form
·       Hospital records (in-case of health insurance)
·       Death certificate (in-case of life insurance
·       Medical records
·       Discharge summary
·       Bills and invoices
·       Claim settlement letter
·       Rejection letter
·       Email communications
·       Any additional support documents

The stronger your documentation, the stronger your case.

Step 5 – Your case is assigned to Insurance Ombudsman

India currently has multiple Insurance Ombudsman offices serving different geographical jurisdictions. The Ombudsman’s annual report lists offices across cities such as Ahmedabad, Bengaluru, Chennai, Delhi, Mumbai, Pune, Kolkata, Hyderabad, Noida and other, each handling complaints from specified districts and states.

Because thousands of complaints are received every year, and your case may take several months before hearing. Depending upon complexity and workload, the process may take

·       3 Months
·       6 Months
·       Sometimes even longer

Patience is important.

Step 6 – Ombudsman Heading

When your matter is listed, you will be informed about the hearing. Who will be present?

·       You (or your authorized representatives)
·       Insurance company representatives
·       Insurance company’s legal team (where applicable)
·       Insurance ombudsman

Both parties are given an opportunity to present

·       Documents
·       Evidence
·       Policy wordings
·       Arguments

The ombudsman can examine policy terms and conditions, applicable regulations, documentary evidence and facts of the case before issuing an award.

Can you Reject the Ombudsman’s Decision?

Yes. If you are dissatisfied with the Ombudsman’s award, you may choose not to accept it and explore other legal remedies, including approaching the appropriate court, subject to applicable law. The Ombudsman is designed to provide an accessible dispute-resolution mechanism, but it does not necessarily extinguish every legal remedy available.

Important Tips that Can Improve your Chances

·       Never hide medical history or material facts while buying insurance
·       Keep every communication in writing
·       Save every email
·       Download policy wording immediately after purchase
·       Preserve all medical records
·       Maintain scanned copies in cloud storage
·       Never submit original documents unless specifically required. Make a scanned copy if necessary
·       Keep chronological records of every conversation
·       Ask for written clarification instead of relying on phone calls
·       Read the rejection letter carefully before responding

Common mistakes Policyholders Make

·       Waiting several months before replying to insurers email communication
·       Depending entirely on an insurance intermediary
·       Losing hospital documents
·       Not reading the rejection letter
·       Missing grievance timelines
·       Filing emotional emails instead of factual representations
·       Assuming that Insurance Ombudsman automatically decides in favor of the policyholders

Remember, the ombudsman examines both, the insurer’s position and the policyholder’s evidence.

Final Thoughts

An insurance claim rejection does not always mean that it is the end of the process. India’s insurance grievance redressal framework provides policyholders with structured mechanism to seek a review before pursuing litigation. The key is to

·       Understand the process
·       Follow the correct sequence
·       Maintain documentary evidence
·       Respect timelines
·       Present facts rather than emotions

The Insurance Ombudsman exists to provide an independent forum for resolving insurance disputes, but success depends on the quality of your documentation, the merits of your case and compliance with the prescribed process.

INSURANCE AWARENESS > INSURANCE IGNORANCE

Helping individuals and families make informed insurance decisions through education, transparency, and awareness.

Last Updated – 14/06/2026
Author Name - Abhishek Borkar

Disclaimer
This article is intended solely for educational and awareness purposes and should not be considered financial, legal, tax, investment, or insurance advice.

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