How To File An Appeal Against An Insurance Claim Denial

By | June 20, 2016

How to file an Appeal against Insurance Claim Denial?

Insurance is definitely handy to protect your family, car, house or any other valuable assets against unforeseen circumstances or emergencies. And then there’s the added advantage of claiming tax exemptions under Section 80C.

(Please note: Exemptions under Section 80C apply to Life Insurance)

But what happens if your insurance claim is denied? That can be extremely disappointing. Take heart though. Not all is lost. You can appeal against an insurance claim denial. We’ll tell you how.

Initial course of action

When your insurance claim gets denied due to reasons unknown to you, here’s your first course of action:

  • Get a written claim denial letter from your insurance company stating why your claim was rejected.
  • Thoroughly check your policy documents to see if the claim denial is legitimate.
  • Do your own research and check the paperwork to see if everything is in place (insurance premium receipts, any break or lapse in the policy, any dispute in the past).
  • Once you are sure that the insurance papers are in place, call your insurer’s customer support to discuss your case. Note down the names of people you speak to and the points you discuss.
  • If the phone call does not yield any result, visit the nearest branch of the insurance company and have a face-to-face discussion about your problem.
  • Give a complaint in writing to senior representatives (like in your insurer’s HQ) if the local branch cannot offer you a desirable solution.

Documents required to file an appeal

When you submit a written complaint to the higher authorities of the insurance company, always remember to submit the following documents with your appeal:

  • Duplicate copy of the insurance policy
  • Copies of the denial letter issued by the insurer
  • Copies of any written correspondence between you and the insurer
  • Duplicate copy of the last payment receipt
  • Copies of the claim form
  • Any of the KYC documents as an identity and address proof

Apart from these, some insurance companies may require additional documents to be submitted along with your insurance claim papers.

In case you do not get any settlement after 30 days of filing your written complaint with the insurance company, you can report the case to the Insurance Ombudsman.

Appeal to Ombudsman

The Government of India has created the Insurance Ombudsman for individual policyholders to have their insurance complaints settled out of court. There are 17 Insurance Ombudsman spread across different parts of the country. Approach the one under whose jurisdiction your insurance company is registered.

You can complain against any partial repudiation of your insurance claim, delay in claim settlement, non-issuance of any insurance document, any dispute about the premium paid or payable, or any legal dispute between you and the insurance company. However, the value of the claim including expenses, should not exceed Rs. 20 lakh.

The Insurance Ombudsman will act as a mediator and help you reach a settlement. In case a settlement does not work out, the Ombudsman will issue an award within three months of getting the complaint. The insurance company has to comply with this within 15 days after it is issued by the Ombudsman, and your insurance amount will be settled. The Ombudsman could also issue ex-gratia payments. You need to give it in writing that you accept the award. The onus also lies on you to inform the insurance firm.

Additional Reading: Top 5 Online Term Plans In India

Remember not to panic when an insurance claim is rejected. Act wisely and follow the legal procedure to claim your insurance amount and surely things will fall in place in no time if your claim is legitimate!

In case you wish to check some insurance options now, you can browse through them right away!

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