Health insurance claim rejected

Without prejudice

[Your name]
[Your address]

Date: 15 Oct 2026

To:
The Grievance Redressal Officer
[Insurance company]

Subject: Grievance about rejection of claim under policy no. [Policy no.]

Sir/Madam,

1. I hold health insurance policy no. [Policy no.] issued by you.
2. The insured was admitted. I made claim for [Amount claimed].
3. You rejected the claim, citing: "pre-existing disease or habit not disclosed".
4. The burden of proving that a material fact was suppressed lies on the insurer (Mahakali Sujatha v Future Generali India Life Insurance, Supreme Court, 2024).
5. Non-disclosure of a condition unrelated to the claim does not defeat the claim (Sulbha Prakash Motegaonkar v LIC, Supreme Court, 2015).
6. Para 17 of the Health Master Circular (2024) requires every repudiation or disallowance to be approved by the Claims Review Committee and to give full details, referring to the specific policy terms. Please confirm that this was followed.
7. Please reconsider and pay [Amount], and reply to me in writing with reasons.

Please also give me:

1. Confirmation that the Claims Review Committee approved this decision, and the date
2. The exact policy clause relied on
3. A copy of my proposal form, and the exact question in it that you say was not answered correctly
4. The contact details of the Insurance Ombudsman for escalation, as your reply must give them

If this is not resolved, I may approach the Insurance Ombudsman or the Consumer Commission.

Enclosures (copies):

1. Policy schedule and wording
2. Rejection or settlement letter
3. Claim form
4. Renewal and porting proof since the first policy
5. Discharge summary
6. Hospital bills with the itemised breakup
7. Doctor's letter on why the treatment was needed
8. Proposal form copy (if I have it)

Date: 15 Oct 2026

To:
The Insurance Ombudsman
Office of the Insurance Ombudsman, [Office (see cioins.co.in/Ombudsman)]

Subject: Complaint under rule 14 of the Insurance Ombudsman Rules, 2017 against [Insurance company]

Ground of complaint (rule 13(1)): (b) partial or total repudiation of claims.

Facts, in date order:

1. I hold health insurance policy no. [Policy no.] issued by the insurer.
2. The insured was admitted. I made claim for [Amount claimed].
3. The insurer rejected the claim, citing: "pre-existing disease or habit not disclosed".

My grounds:

1. The burden of proving that a material fact was suppressed lies on the insurer (Mahakali Sujatha v Future Generali India Life Insurance, Supreme Court, 2024).
2. Non-disclosure of a condition unrelated to the claim does not defeat the claim (Sulbha Prakash Motegaonkar v LIC, Supreme Court, 2015).
3. Para 17 of the Health Master Circular (2024) requires every repudiation or disallowance to be approved by the Claims Review Committee and to give full details, referring to the specific policy terms. Please confirm that this was followed.

Monetary loss: [Amount]

Relief sought: Payment of [Amount].

Declaration

1. I made a written representation to the insurer on [Date sent], and the insurer has not replied within one month of receiving it.
2. This complaint is made within one year of the insurer's reply or, where there was no reply, within one year after one month from the date I sent my representation.
3. The same matter is not pending before, and has not been decided by, any court, consumer forum or arbitrator.
4. I understand the Ombudsman's award, including expenses, cannot exceed ₹50 lakh.
5. The information given above is true to the best of my knowledge and belief.

Enclosures (copies):

1. Policy schedule and wording
2. Rejection or settlement letter
3. My letter to the insurer's Grievance Redressal Officer, with proof of sending
4. The insurer's reply, if any
5. Claim form
6. Renewal and porting proof since the first policy
7. Discharge summary
8. Hospital bills with the itemised breakup
9. Doctor's letter on why the treatment was needed
10. Proposal form copy (if I have it)