Case Study: ₹8.07 Lakh Health Insurance Claim Dispute Resulting in ₹6.25 Lakh Settlement
When a health insurance claim is rejected, policyholders may be left wondering what went wrong and whether anything can be done to challenge the decision.
This case involved a health insurance claim of ₹8,07,953 that was rejected by the insurance company on the stated ground that past treatment records had not been submitted.
After reviewing the customer’s documents, medical history and correspondence with the insurer, our team found that the matter required further examination. The customer’s case was subsequently represented before the Ombudsman Forum.
The matter was decided in the customer’s favour, and ₹6,25,000 was settled.
Important: This case study describes the facts and outcome of a particular matter. The outcome of any insurance claim dispute depends on its individual facts, policy terms, documents and applicable grievance-redressal process.
Case at a Glance
| Particular | Details |
|---|---|
| Category | Health Insurance |
| Claim Amount | ₹8,07,953 |
| Issue | Claim rejected for alleged non-submission of past treatment records |
| Forum | Ombudsman Forum |
| Outcome | Customer’s case decided in their favour |
| Amount Settled | ₹6,25,000 |
The source case study records the original claim amount as ₹8,07,953 and the eventual settlement as ₹6,25,000.
Why Was the Health Insurance Claim Rejected?
The insurance company stated that the insured had not submitted past treatment records and treated this as non-submission of required documents.
The insurer’s stated position was that, without the requested documents or details, it was unable to process the claim further.
For a policyholder, such a rejection can be particularly concerning when they believe that the requested information has already been provided.
That was the central issue examined in this case.
The Customer’s Response to the Insurer
According to the case documents, the customer had responded to the insurer’s queries at the company’s branch office.
The customer submitted a detailed explanation along with hospital records and other relevant documents. Despite these submissions, the claim was subsequently rejected.
The customer was therefore dissatisfied with the rejection and sought further consideration of the matter.
Review of the Medical History
An important part of the case concerned the distinction between the customer’s previous medical history and the later diagnosis for which the claim arose.
The case records state that the patient was first diagnosed with Coronary Artery Disease (CAD) on August 6, 2025.
According to the information provided in the case, there was no previous history, symptoms, consultation, treatment or suspicion relating to CAD before that date.
The patient had previously suffered from Pulmonary Tuberculosis (PTB) in February 2021. The case records state that the patient completed treatment and was declared cured by the treating physician, with the condition having fully resolved and no subsequent complications.
The available documents relating to the earlier PTB treatment were also submitted to the insurance company and the Ombudsman.
This medical history was therefore an important part of presenting the customer’s position.
Our Approach to the Insurance Claim Dispute
Our team undertook a detailed review of the matter before representing the customer’s case.
1. Examination of the Claim Documents
The available insurance, hospital and medical documents were reviewed to understand the circumstances surrounding the claim and the insurer’s rejection.
2. Review of the Rejection Reason
The specific reason stated by the insurer was examined, particularly the allegation concerning non-submission of past treatment records.
3. Review of the Customer’s Responses
The customer’s responses to the insurer’s queries, including the explanation letter and hospital records submitted at the branch office, were considered.
4. Clarification of Medical History
The customer’s previous PTB treatment and subsequent CAD diagnosis were clearly presented as part of the case.
5. Representation Before the Ombudsman
After reviewing the available material, the matter was represented before the Ombudsman Forum with supporting evidence and relevant regulatory considerations.
Outcome: ₹6.25 Lakh Settlement
The representation resulted in a favourable outcome for the customer.
The case records state that the forum ruled in the customer’s favour and that ₹6,25,000 was settled.
The outcome demonstrates why policyholders should carefully examine the reasons given for a health insurance claim rejection and ensure that their documents, medical history and responses are properly presented through the available grievance-redressal process.
What Can Policyholders Learn From This Case?
A rejected health insurance claim should not necessarily be treated as the end of the matter.
Depending on the circumstances, policyholders should consider:
Keep Complete Documentation
Maintain copies of the health insurance policy, claim forms, hospital records, medical reports, bills and all correspondence with the insurer.
Preserve Communication With the Insurer
Keep records of query letters, responses, emails, letters and documents submitted to the insurance company.
Understand the Exact Reason for Rejection
A claim rejection letter should be examined carefully. The specific reason for rejection can determine what further action may be appropriate.
Clarify Previous Medical Conditions
Where previous medical history is relevant, it is important to present accurate medical records and clearly distinguish previous treated conditions from subsequent diagnoses where the medical facts support that distinction.
Consider the Available Grievance Mechanisms
Where a policyholder believes that a claim has been wrongly rejected or inadequately considered, the applicable grievance-redressal mechanisms may provide avenues for further review.
Why a Claim Rejection Should Be Reviewed Carefully
Insurance claims can involve substantial documentation and medical information. A rejection may refer to missing documents, medical history, policy conditions or other reasons.
The important question is not simply whether a claim has been rejected, but whether the rejection should be accepted in light of:
- the insurance policy;
- the claim documents;
- the medical records;
- the correspondence exchanged with the insurer;
- the information actually submitted by the policyholder; and
- the applicable grievance-redressal mechanism.
In this case, the customer’s documents and medical history were reviewed and the matter was subsequently represented before the Ombudsman Forum.
Frequently Asked Questions
What should I do if my health insurance claim is rejected?
Start by carefully reviewing the insurer’s rejection letter and identifying the specific reason given for rejection. Collect your policy documents, medical records, claim documents and all communication with the insurer. A professional review can help you understand the available options.
Can a rejected health insurance claim be challenged?
Depending on the circumstances, a policyholder may have access to the insurer’s grievance-redressal process and other applicable mechanisms, including the Insurance Ombudsman process where eligible.
What documents should I keep after a health insurance claim rejection?
Important records may include the insurance policy, claim form, hospital bills, discharge summary, medical reports, prescriptions, investigation reports, correspondence with the insurer and copies of documents submitted in response to insurer queries.
Can previous medical treatment affect a health insurance claim?
Previous medical history can be relevant to an insurance claim depending on the circumstances and the applicable policy terms. It is therefore important to provide accurate medical information and supporting records when responding to an insurer’s queries.
What was the result of this health insurance claim case?
In this case, the customer’s matter was decided in their favour before the Ombudsman Forum, resulting in a settlement of ₹6,25,000.
Does a successful case guarantee that another insurance claim will also succeed?
No. Each insurance dispute is decided based on its own facts, policy terms, documents, medical evidence and applicable legal or regulatory framework. This case study should not be treated as a guarantee of a particular outcome.
Looking for Assistance With a Rejected Health Insurance Claim?
If your health insurance claim has been rejected and you believe that the decision does not properly reflect the documents or circumstances of your case, obtaining a detailed review may help you understand the available options.
Nidaan provides assistance in reviewing insurance claim disputes and presenting cases through appropriate grievance-redressal mechanisms.
Contact Nidaan
Have you received a health insurance claim rejection?
Contact Nidaan to discuss your case and understand the next steps that may be available based on your documents and circumstances.
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Case Study Disclaimer
This case study is provided for informational purposes and is based on the facts and documents available for the particular matter described above. It does not constitute legal advice, insurance advice or a guarantee of a similar result in any other matter.
Every insurance claim and dispute is different and depends on the applicable policy terms, medical records, documents, facts and grievance-redressal process. Readers should obtain appropriate professional advice based on their individual circumstances before taking action.
Case Study Author: Dr. Ashish Dubey
Designation: General Manager – Medical
Subject-Matter Contribution: Medical and Health Insurance Claims
Published by: Nidaan – The Legal Consultant
