Employer group health insurance claim rejected — who do I complain to?

Under your employer's policy the insurer still decides the claim and owes you its reasons, so complain in writing to the insurer's grievance officer; HR and the TPA can help, but they do not make the decision. As a covered member you can also use Bima Bharosa yourself, and the Council for Insurance Ombudsmen says a member of a group policy can approach the Ombudsman where the claim is payable to that member, once the insurer has rejected the complaint, replied unsatisfactorily or not replied within one month. Ask HR for a copy of the group policy terms first.

A group policy has more parties than one you buy yourself: your employer, the insurer, possibly a TPA, and sometimes a broker. When a claim is rejected, it can feel as if each one points to another. The rules say clearly who is who.

Who is who in a group policy

• Your employer: The master policyholder. Employees are members of the group, and the employer must share the group policy with all members.^[1]
• The insurer: Decides the claim. A health claim cannot be repudiated without the approval of the insurer's Product Management Committee or Claims Review Committee, and a rejection must give full details with reference to the specific policy terms.^[2]
• The TPA: Engaged by the insurer to provide services on its behalf, especially at the time of a claim; see when a TPA rejects a claim.^[1]
• You: Claims under an employer group policy are paid directly to the employee or the beneficiary.^[1]

A protection for new joiners

IRDAI's health master circular says no claim shall be denied because the insurer does not have the details of members of the group. If your claim was refused because your name had not yet reached the insurer from the employer, quote this rule.^[2]

Where to complain

1. 1

   Get the documents

   The group policy terms from HR, your e-card or certificate of insurance, and the TPA's claim number.

2. 2

   Talk to HR or the benefits team

   They can explain what the group terms say and chase the insurer, but this is informal and does not replace a written complaint.

3. 3

   Write to the insurer's grievance officer

   Put the complaint in writing with documents and take a dated acknowledgement. A beneficiary of a policy counts as a complainant under IRDAI's regulations, and the insurer should resolve the complaint within 14 days.^{[3, 4, 1]}

4. 4

   Use Bima Bharosa if needed

   You can register the complaint on IRDAI's Bima Bharosa portal, entering your certificate of insurance number for a group policy and the claim number, which is mandatory for claim complaints.^{[5, 6]}

5. 5

   The Insurance Ombudsman

   The Ombudsman Rules cover group insurance policies, and the Council for Insurance Ombudsmen says a member covered under a group policy can approach the Ombudsman where the claim is payable to that member. Whether or not you used Bima Bharosa, you must first have complained to the insurer in writing, and the insurer must have rejected the complaint, replied unsatisfactorily or not replied within one month of receiving it. You then have one year from its rejection or unsatisfactory reply or, if it never replied, from the end of one month after you sent your complaint.^{[7, 8]}

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.

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