Maternity claim rejected — waiting period, sub-limit or 'not covered'?

First check whether your policy covers maternity at all: IRDAI's 2024 product regulations treat maternity as something insurers may design products for, and at least one insurer's product excludes childbirth expenses altogether. If your policy does cover maternity, look at the conditions it sets: a maternity waiting period, a sub-limit, or the terms for newborn cover, each set by your own wording and schedule. Find the maternity clause and the exclusions list before you reply.

Maternity rejections fall into two different kinds. Either the policy does not cover childbirth at all, in which case the question is whether an exception applies, or it does cover it on conditions, in which case the question is whether those conditions were met.

Is maternity covered at all?

IRDAI's Insurance Products Regulations, 2024 allow insurers to design products specifically for maternity, and the standard Customer Information Sheet lists maternity as a coverage item a policy may include. It is a feature of the product, not a cover every policy must carry.^{[1, 2]}

One insurer's product, for example, excludes medical expenses traceable to childbirth, including complicated deliveries and caesarean sections, except ectopic pregnancy. It also excludes miscarriage, unless it was due to an accident, and lawful medical termination of pregnancy.^[3]

If maternity is covered: what the rejection may rest on

• A maternity waiting period: A policy that covers maternity may make it wait for a period from the start of cover. Specific waiting periods can run up to 36 months, so check the exact period in your wording and count continuous cover from your first policy.^[1]
• A sub-limit: A cap on what the policy pays for a delivery. A sub-limit means the insurer pays nothing above the pre-defined limit, even if the sum insured is not used up.^[3]
• Newborn cover: Whether the baby is covered, from when, and for what, is set by the policy. Read the newborn clause separately from the delivery clause.

Exceptions worth checking

• Ectopic pregnancy: Carved out of the childbirth exclusion in the product quoted above.^[3]
• Miscarriage due to an accident: Also carved out of that exclusion. If the miscarriage followed an accident, say so and attach the record.^[3]
• Complications during pregnancy: If a condition during pregnancy was treated, ask the insurer which clause it applied, and compare it with the illness cover in your policy.

Group policies through an employer

An employer's group policy has its own terms, which may treat maternity differently from a policy you buy yourself. The employer must share the group policy with its members, so ask HR for the group terms and read the maternity section there. For who to complain to under a group policy, see group health claims.^[2]

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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