How to match each document to the insurer's reason (an evidence map)

An evidence map is a simple table: each statement the insurer relies on in one row, and next to it the document that proves, disproves or explains it. Build it from the reason in the insurer's letter, not from the pile of papers, and mark every statement you cannot yet answer. The gaps tell you what to collect, and the finished map lets anyone reviewing your complaint follow your answer in minutes.

Start from the decision letter. For a health claim, an insurer that rejects or partly disallows the claim must give "full details giving reference to the specific terms and conditions of the policy document". Those details, sentence by sentence, are the rows of your map.^[1]

The map also does work you will need later. A complaint to the Insurance Ombudsman must set out "the facts giving rise to the complaint, supported by documents". A map made now is most of that job.^[2]

Lay it out in four columns

How to fill it in

1. 1

   Split the reason into separate statements

   One row per factual claim. A single sentence can hide two: a date and a clause, or a diagnosis and a waiting period.

2. 2

   Note where each statement comes from

   The paragraph of the letter, the clause number, the investigator's report or the hospital record the insurer names.

3. 3

   Find the document that answers it

   Mark whether it proves the statement wrong, shows it does not apply, or explains it.

4. 4

   Check the clause itself

   Read the clause in your own wording. All exclusions must be written into the policy document, and no deduction may be made "in the name of any other exclusions".^[3]

5. 5

   Turn the gaps into requests

   A row with no document is your to-do list: the hospital (getting records), the treating doctor (a doctor's letter) or the insurer (the documents it relied on).

What can answer each reason

• Pre-existing disease: The definition turns on diagnosis, or medical advice or treatment, within 36 months before the policy began, so the dates of first diagnosis, advice or treatment, set against the policy start date, decide this row. When a claim is rejected on this ground or a waiting period, the Council for Insurance Ombudsmen's procedure page lists, among the documents to send with a complaint, copies of earlier policies covering the 48 months before the current one.^{[4, 5]}
• Non-disclosure: The proposal form as submitted, showing the exact question. For a life policy, IRDAI's master circular says no claim shall be repudiated without "legally tenable evidence"; ask to see what the insurer relies on, and put it in the map. See getting a copy of the proposal form.^[6]
• Not medically necessary: The treating doctor's notes, the admission advice and the discharge summary, in the doctor's own words.
• Amount deducted: The insurer's computation sheet set against the itemised bill, line by line. See reading the settlement sheet.
• Late intimation or late documents: Proof of the dates you told the insurer and sent each document. IRDAI's 2024 master circular says no claim shall be rejected or closed for want of documents or for delayed intimation.^[3]

Using the finished map

Number your enclosures in the same order as the rows, and refer to each by its number when you write your grievance. Whoever reads it — the grievance officer first, perhaps others later — can then check each answer against its document without hunting for it.

ClaimAssure is an independent private platform. It is not an insurer, IRDAI, Bima Bharosa or the Insurance Ombudsman, it never files anything on your behalf, and it cannot promise any outcome. What it does is read your documents and show you what they say.

More on claim documents and evidence