An insurer may reject or repudiate a claim for reasons such as exclusion, failure to disclose, breach of policy condition, delay, lack of evidence or disagreement over the event insured. The correct response depends on the precise ground stated in the decision.

Start with the repudiation letter and policy schedule rather than a general complaint that the claim was unfairly denied. The objective is to test whether the insurer’s reason is supported by the contract, proposal record and claim evidence.

1. Read the exact repudiation ground

Identify the clause, exclusion or factual allegation relied upon. If the letter uses broad wording, ask for the policy provision and documents forming the basis of the decision.

Do not assume that a rejection based on “failure to disclose” or “existing condition” is self explanatory; the insurer’s factual and contractual basis should be understood.

2. Compare the proposal form with what the insurer alleges

In disclosure disputes, obtain the signed proposal form, declarations, medical records or other information actually provided at inception. Questions asked, answers recorded and the materiality of the alleged omission may all matter.

If an intermediary completed the form, preserve communications about how information was collected.

3. Build the claim evidence file

Keep the policy, endorsements, premium record, claim form, surveyor/medical documents, bills, photographs, police documents where relevant and every insurer request for information.

A chronology showing when the event occurred, when it was reported and when documents were supplied can help address delay based objections.

4. Use the insurer grievance process in writing

Send a concise representation addressing the stated repudiation ground with the key supporting documents. Ask for a reasoned response and keep the grievance reference.

If unresolved, IRDAI’s Bima Bharosa grievance system and the Insurance Ombudsman framework may be relevant depending on the policyholder and dispute.

5. Choose the forum based on the dispute

Insurance disputes can raise contractual, consumer and regulatory issues. The appropriate forum depends on the claimant, value, policy, relief and procedural history.

Do not file multiple inconsistent complaints without understanding how the routes interact.

Documents to preserve

The proposal and claim file should be kept together.

  • Policy schedule, wording, endorsements and premium receipts.
  • Proposal form and declarations made at inception.
  • Claim form and supporting medical/survey/repair records.
  • Repudiation letter and internal grievance response.
  • Bima Bharosa/Ombudsman or other complaint records if escalated.

Reference framework

Legal framework referred to in this article

  • Insurance Act, 1938
  • Applicable IRDAI policyholder protection and grievance framework
  • Insurance Ombudsman Rules, 2017
  • Consumer Protection Act, 2019 where applicable

Primary materials

This article summarises the legal and regulatory framework relevant to the topic. Later amendments, factual differences and applicable directions may affect the position.