My spouse was diagnosed with a severe neurological condition described as bacterial meningitis with encephalitis. We filed a critical illness claim, but the insurer rejected it, saying the illness is not covered. Is there any way to challenge this?
-Name withheld
A rejection does not always mean the claim is invalid. The first step is to review the policy document carefully and check the list of covered critical illnesses. In many policies, bacterial meningitis is specifically included, provided certain diagnostic and clinical conditions are met.
In a similar case, a thorough review revealed that the illness was indeed listed among the 32 covered critical illnesses, and the medical certificate clearly confirmed the diagnosis and severity. When the policy wording and medical evidence match, the rejection can and should be contested.
The next step is to escalate the matter to the insurer’s grievance redressal team. This involves submitting a concise but comprehensive representation, highlighting the relevant policy clauses and attaching all supporting medical records.
In the case referred to, detailed justifications were provided, including the diagnosis, hospitalization records, and confirmation that the illness fulfilled the criteria mentioned in the policy. Yet, the insurer continued to uphold the rejection without offering any fresh reasoning or evidence. When this happens, policyholders should not lose hope—there is a further remedy available.
Filing a complaint is free of cost, and the ombudsman examines both medical evidence and policy terms.
During the hearing in this case, the policyholder presented all relevant documents, including hospital records and a certificate from the treating doctor confirming that the patient had suffered a permanent neurological deficit for more than six weeks—a key eligibility criterion under most critical illness policies. The insurer, however, could not produce any counter-evidence to dispute the diagnosis or the clinical condition.
After reviewing the submissions, the ombudsman ruled in favour of the policyholder and directed the insurer to pay the critical illness claim amount to the nominee. This decision reaffirmed an important lesson: when policy terms clearly support the claim and medical evidence is complete, an unfair rejection can be successfully overturned through proper escalation.
Always read policy wording carefully, maintain complete medical documentation, and make use of the grievance and ombudsman mechanisms when needed.
Many rejections can be resolved simply because the facts and the policy conditions are on the consumer’s side.
Shilpa Arora, co-founder & COO, Insurance Samadhan. If you have any personal finance query, write to us at [email protected] to get it answered by experts.