Archive · 25 Dec 2025
Insurer Rejects Critical Illness Claim: Steps to Challenge
A person's spouse was very sick with a serious brain infection.
They asked their insurance company for money to help, but the company said no.
The person checked their insurance papers and found that the sickness should be covered.
They sent all the doctor's papers to the insurance company, but the company still said no.
So, they went to a special person called an ombudsman who listens to problems like this.
The ombudsman looked at all the papers and said the insurance company should give the money.
The person learned that it's important to read the insurance papers carefully and keep all the doctor's papers to show if there's a problem.
A policyholder's spouse was diagnosed with bacterial meningitis with encephalitis, and the critical illness claim was rejected by the insurer.
The policyholder reviewed the policy document and found that bacterial meningitis is often included in the list of covered critical illnesses.
The insurer's grievance redressal team was approached with a comprehensive representation and supporting medical records.
The ombudsman examined the medical evidence and policy terms and ruled in favor of the policyholder.
The decision reaffirmed the importance of thorough policy review and complete medical documentation in contesting unfair rejections.
- Who
- A policyholder whose spouse was diagnosed with bacterial meningitis with encephalitis
- What
- The insurer rejected the critical illness claim, stating the illness is not covered
- When
- After filing the claim and receiving a rejection
- Where
- India (based on the mention of the ombudsman process)
- Why
- The insurer claimed the illness was not covered under the policy
- Illness Diagnosed
- Bacterial meningitis with encephalitis
- Claim Status
- Rejected by insurer
- Policy Review
- Check list of covered critical illnesses
- Escalation Step
- Submit to grievance redressal team
- Ombudsman Complaint
- Free of cost, examines medical evidence and policy terms
- Key Eligibility Criterion
- Permanent neurological deficit for more than six weeks
- Outcome
- Ombudsman ruled in favor of the policyholder