Your claim can be rejected by:

• TPA (if one is availing cashless facility), or
• By Insurance Company.

In case the claim is rejected by TPA, one should approach the insurance company. The insurance company may allow your reimbursement or reject your claim.

Once the claim is rejected by the insurance company, one should approach Grievance Cell of the respective Insurance Company.

Grievance cell would address to your complaint within 30 days of filing it. It may approve your claim or reject it.

In case the claim is approved by Grievance Cell, the Insurance Company would reimburse one’s expenses.

In case the claim is

• rejected by the Grievance Cell of the Insurance Company, or
• no response has been received by the insured from the Grievance Cell by thirty days of filing the application with the Grievance Cell

The insured has two options:

• One can approach Ombudsman Cell which is bound to address the complaint by 90 days of filing it, or (see write up on ombudsman)
• One can approach Consumer Disputes Redressal Courts directly without approaching Ombudsman Cell. Before approaching Consumer Disputes Redressal Courts, one should send a reminder to a Grievance Cell about the fate of one’s application if no reply has been received. In case again no reply is received or the insured is not satisfied with the order of the Grievance Cell, then one can file an application with the Consumer Disputes Redressal Courts (see write up on consumer dispute redressal courts).

• If the Ombudsman Cell approves the claim of the insured, then the Insurance Company would reimburse all the expenses incurred by the insured.
• In case the insured is not satisfied with the award of Ombudsman Cell then the insured can approach either Consumer Disputes Redressal Courts* or other Civil Court.

*However Hon’ble Shri Ashok Bhan, President, National Consumer Disputes Redressal Commission, has stated as quoted below:
“HOWEVER, WE CANNOT INTERFERE WITH THE OMBUDSMAN’S JUDGEMENT. WE CAN ONLY BEEF UP THE COMPENSATION AMOUNT.”