Reimbursement Rejection in Health Insurance
A Reimbursement Rejection means the insurer or TPA has refused to pay back the medical expenses you submitted after treatment, based on the terms of your policy.
Common Reasons for Reimbursement Rejection
Claim not covered under policy
Treatment, procedure, or illness is excluded (e.g., cosmetic surgery, dental, pre-existing condition within waiting period)
Incomplete or missing documents
Missing bills, prescriptions, claim form, or discharge summary
Treatment in a non-eligible hospital
Hospital is not registered or doesn’t meet insurer’s requirements (especially for day care claims)
Delay in submission
Claim submitted after the allowed time window (usually 15–30 days after discharge)
Sum Insured exhausted
You’ve already used up your yearly coverage limit
Claim form or documents not properly filled
Missing signatures, unclear diagnosis, no doctor’s stamp, etc.
Discrepancy or suspicion
Bills seem inflated or inconsistent with standard treatment
In some cases, an investigation is triggered
What You Should Do Next
Read the Rejection Letter Carefully
The insurer/TPA will mention the exact reason for rejection.
Contact Support
Reach out to your HR SPOC, insurance support team, (if you’re using them) to understand the reason in detail.
Submit Missing Documents or Clarifications
If it’s a documentation issue, you can resubmit the required papers with a claim reference number.
File an Appeal
If you believe the rejection is not justified, you can:
Send a formal appeal with clarification
Include supporting documents like doctor letters, hospital stamps, etc.
Ask your insurance support partner to escalate or challenge the decision