Policyholders can successfully challenge unfair decisions.(Representative Image)

A policyholder recently faced trouble after his/her spouse was diagnosed with a serious brain-related illness. The condition was identified as bacterial meningitis with encephalitis. Believing the illness was covered, the family filed a critical illness claim with their insurer.

However, the insurance company turned down the request. The reason given was that the illness did not fall under the list of covered conditions. This left the family confused and unsure about the next step, especially at a time when medical stress and costs were already high.

Why A Rejected Claim May Still Be Valid

A claim rejection does not always mean the insurer is right. The first step is to read the policy document carefully. Most critical illness plans clearly list the illnesses they cover. In many policies, bacterial meningitis is included, but only if certain medical conditions are met.

In a similar case, a close review of the policy showed that the illness was listed among 32 covered conditions. The medical records also clearly confirmed the diagnosis and seriousness of the disease. When both the policy terms and medical proof match, the rejection can be questioned.

How To Raise The Issue With The Insurer

The next step is to approach the insurer’s grievance team. This means sending a clear written request that explains why the claim should be accepted. It is important to point out the exact policy clauses and attach all medical reports.

In the case mentioned, the policyholder shared hospital records, diagnosis details, and proof of treatment. Despite this, the insurer stuck to its earlier decision and did not provide any new explanation. This is when many people give up, but there is still another option available.

When The Insurance Ombudsman Can Help

If the insurer does not resolve the issue, the policyholder can approach the insurance ombudsman. Filing a complaint here does not cost anything. The ombudsman reviews both the policy terms and the medical evidence.

During the hearing in this case, the policyholder submitted hospital documents and a doctor’s certificate. The records confirmed that the patient had a lasting brain-related problem for over six weeks, which is an important requirement in many critical illness policies. The insurer failed to provide proof to challenge these findings.

What This Case Teaches Policyholders

After reviewing all details, the ombudsman ruled in favour of the policyholder and asked the insurer to pay the claim amount to the nominee. This shows that unfair claim rejections can be overturned if the policy terms are clear and the documents are in order.

It is always wise to read your policy closely, keep complete medical records, and use the grievance and ombudsman process when needed. Many rejected claims can be resolved because the facts and the policy are on the customer’s side.