My husband was diagnosed with bacterial meningitis and encephalitis. We filed a critical illness claim, but the insurer rejected it, saying the illness was not covered under the policy. What can policyholders do in such situations?
-Name withheld on request
Policyholders should first carefully review the policy wording and the list of covered critical illnesses mentioned in the policy document. In many cases, illnesses like bacterial meningitis are specifically covered, subject to certain conditions.
The next step is to verify whether:
- The diagnosis matches the illness definition in the policy,
- The required medical documents and certificates have been submitted,
- The severity criteria mentioned in the policy have been fulfilled.
If the treating doctor has certified neurological complications, permanent impairment, or prolonged disability, those documents become extremely important while contesting the rejection.
Policyholders should then raise a detailed grievance with the insurance company’s grievance redressal department, attaching relevant policy clauses, hospital records, diagnostic reports, treating doctor’s certificate, discharge summaries and treatment details.
If the insurer continues to reject the claim without adequate medical justification, the matter can be escalated to the insurance ombudsman.
The ombudsman generally examines:
- Whether the illness falls within the policy definition,
- Whether medical evidence supports the diagnosis,
- Whether policy conditions have been fulfilled,
- Whether the insurer has valid grounds for rejection.
In neurological illness cases, certificates from the treating specialist confirming permanent neurological deficit, duration of impairment, hospitalization details, and diagnostic findings can significantly strengthen the complaint.
The insurer is also expected to provide medical or legal reasoning to justify rejection. If it fails to do so, the ombudsman may direct the insurer to settle the claim as per policy terms.
Policyholders should never assume that a claim rejection is final. Many claims are rejected due to incorrect interpretation of policy wording, incomplete assessment of medical records, or procedural issues.
Consumers should:
- Preserve all medical records carefully,
- Obtain detailed certificates from treating doctors,
- Read the illness definitions in the policy,
- Escalate grievances formally in writing,
- Approach the insurance ombudsman when justified.
A well-documented case supported by proper medical evidence can often help policyholders secure rightful claim benefits.
Shilpa Arora, is co founder and COO of Insurance Samadhan