The Denial Letter Is Not the Verdict A rejected health insurance claim feels like the end of the road. In India, it is usually the start of an appeal that the policyholder wins more often than not. The cancer treatment is over and the discharge papers are signed, but the hospital will not release the patient until the insurer pays. The Third-Party Administrator then denies the cashless request, and the family scrapes together four lakh rupees from savings, fixed deposits, and relatives. The patient recovers at home while the family files for reimbursement and waits the usual thirty days. Then a message asks for Indoor Case Papers and certificates that are hard to obtain weeks after discharge, and the claim is rejected outright. The money is already gone. Yet this is recoverable. A repudiated claim is not a final ruling, and the grievance system, by the regulator's own figures, sides with policyholders more often than insurers. Read the Repudiation Letter A rejected claim arrives as a written repudiation letter from the insurer or its Third-Party Administrator, which by IRDAI rules must state the reason and quote the policy clause relied on. Three things matter: the claimed amount against the allowed amount, showing what was refused and whether the repudiation is total or partial; the reason codes behind each item; and the policy clause cited, checked against your own schedule and the IRDAI Master Circular. Note the clock: you have one year from the final rejection to approach the Insurance Ombudsman, so move briskly. Identify the Type of Denial Every denial is one of three types, each calling for a different reply. Administrative or technical. A paperwork error: a missing document, a typo, a late submission. Supply what is missing, correct it, or show the hospital filed late, not you. Medical or clinical. The insurer's medical team disputes whether treatment was necessary. Answer with a clinical justification letter explaining why the chosen treatment was right and the alternatives unacceptably risky. Policy exclusion or contractual. The insurer says the policy does not cover the condition. Prove it was not pre-existing, or that the exclusion was never disclosed at sale, itself a breach of IRDAI rules. Challenge the Reasons That Can Be Challenged Many refusals look like settled fact but rest on judgement, and can be contested.