If an insurer has rejected a claim, the first mandatory step is a written representation to the insurer's grievance officer. If that fails or is ignored, you can go to the Insurance Ombudsman under the Insurance Ombudsman Rules 2017, or to the consumer commission under the Consumer Protection Act 2019. Both routes are free or low-cost, and neither needs a lawyer to start, but a clear paper trail decides the outcome.
When this matters
- A health, motor, fire or travel claim has been repudiated, part-paid or delayed.
- The insurer has not responded within the time its grievance policy allows.
- A no-claim bonus or policy value has been cancelled unfairly.
- A motor accident or vehicle claim has been repudiated on a policy ground; see our motor accident claims page for that route.
- You have been told the policy lapsed, though you had paid the premium.
Our consumer protection practice and the consumer formats guide cover the drafting side.
Common grounds of repudiation
- Non-disclosure or misrepresentation of a pre-existing disease or of material facts at the proposal stage.
- Exclusion clause — the claim is said to fall outside what the policy covers.
- Waiting period for a declared condition or for maternity cover.
- Sub-limit or room-rent ceiling breached under a health policy.
- Policy lapse due to a missed or bounced premium, or a claim filed after the renewal gap.
- Documents missing or allegations that the loss itself was not proved.
An insurer is expected to state its reasons and to do so on the policy wording, not on a bare assertion. A repudiation that quotes no clause and answers no document is weak, and that weakness is exactly what a representation to the grievance officer, and later the Ombudsman, is designed to expose. Write down each ground as a separate point, because each has to be met by a document, not by an argument alone.
Step by step
1. Build the file before you complain
Read the repudiation letter carefully and note each specific reason it gives. Collect the proposal form, the policy schedule and wording, the premium receipts, the claim form, the hospital or repair records and every email and message exchanged with the insurer. A complaint is only as strong as the documents behind it.
2. Write the representation to the grievance officer
The Insurance Ombudsman Rules require that the insurer's own grievance machinery be given a chance first. Address a written representation to the designated grievance officer of the insurer, quote the policy number and the claim number, answer each repudiation ground in turn, and ask for a reasoned decision within the period the policy and the rules contemplate. Keep proof of dispatch and of receipt.
3. Approach the Insurance Ombudsman
Under the Insurance Ombudsman Rules 2017 a complaint lies to the Ombudsman for the area, and it can be filed by an individual policyholder or by certain small entities. The Ombudsman can direct the insurer to settle the claim, to pay the amount the policy provides, or to make a partial payment, and the award is binding on the insurer. The value the Ombudsman can award is limited by a ceiling fixed under the scheme, so a very large claim may go to the consumer commission or a civil court instead. Filing is simple, and the Ombudsman route is free.
4. The parallel route before the consumer commission
A repudiation that is without basis can amount to a deficiency in service under the Consumer Protection Act 2019. A complaint is filed before the District, State or National Commission depending on the value of the claim, and can be filed online through the e-Daakhil portal. The commission can order payment of the claim, compensation for mental agony, and costs. Choose the forum deliberately, because the same claim should not be pressed in two places at once.
Documents to file
- The repudiation letter and any earlier correspondence with the insurer.
- Proposal form, policy schedule and the full policy wording, including endorsements.
- Premium payment receipts and bank statements showing payment.
- Claim form and its acknowledgements, with all supporting bills and records.
- The representation to the grievance officer, with postal or email proof of delivery.
- Identity and address proof of the complainant, and details of the insurer.
Timelines and limitation
An Ombudsman complaint should be made within the period the Rules allow after the insurer's final reply, and a consumer complaint should be filed within the limitation fixed by the Consumer Protection Act 2019 from the date the cause of action arose. Do not wait years; delay weakens both routes. If the insurer delays even a genuine claim, treat that delay as itself a ground of complaint and keep records of every follow-up.
Common questions
Do I need a lawyer to file before the Ombudsman?
No. The Ombudsman route is built for policyholders to use directly, and it is free. A lawyer still helps where the repudiation turns on reading the policy wording or on a large sum that needs the consumer commission.
Can I go to the Ombudsman and the consumer commission together?
No. You should pick one forum. Pressing the same grievance in two places invites the second forum to reject it as already agitated elsewhere.
What if the insurer never replied to my representation?
Silence is itself a ground to complain. Attach proof that the representation was sent and received, and state that no reasoned reply came within the time the grievance machinery contemplates.
Does a rejected claim mean the end of the matter?
No. A repudiation is an insurer's decision, not a court's. Both the Ombudsman and the consumer commission can set it aside if the policy wording and the record support the claim.
FileX Advocates & Legal Consultants, Kolkata, drafts and files these matters before the Calcutta High Court, City Civil and Sessions courts, magistrate, family, consumer and tribunal forums. Call +91 7439811422 or WhatsApp us for a free first consultation.