Group Health Insurance Claim Rejected in India? Know Your Rights

Group health insurance — provided through an employer or association — is the most common form of health cover in urban India. When a claim under a group policy is rejected, employees often face a different set of rules than individual policyholders. The master policy, the employer's TPA arrangement, and IRDAI portability rules all create distinct rights that most employees are unaware of.

The master policy governs — not the summary card

In a group health insurance arrangement, the employer is the policyholder and the employees are the insured beneficiaries. Employees typically receive a summary card, a benefit booklet, or a short-form certificate — but these documents do not constitute the insurance contract. The master policy between the insurer and the employer is the governing document.

If the insurer cites an exclusion or limitation that is not expressly stated in the master policy, the rejection fails. Equally, if the summary card you received is more generous than the master policy, the master policy governs and limits the cover. Always request and read the full master policy when a claim is disputed — your employer is obligated to provide it to you.

Pre-existing conditions in group policies

Individual health policies routinely impose a 2–4 year waiting period for pre-existing diseases (PED). Many group health policies, by contrast, cover pre-existing conditions from day one or after a short initial period. This is because group policies are underwritten on the collective risk of the entire employee pool, not the individual's medical history.

If your claim for a pre-existing condition was rejected under a group policy, the first step is to verify the master policy's specific PED terms. If the master policy covers PED from inception or after a waiting period you have already served, the rejection on PED grounds is invalid. Do not assume individual policy PED rules apply to a group policy.

Employment status at the time of hospitalisation

A claim can only be rejected for cessation of employment if the hospitalisation itself occurred after employment ended and the cover lapsed. If you were admitted to hospital while still employed, the claim is covered under the policy that was in force at the time of admission. The fact that discharge, billing, or claim submission happens after you leave the job does not extinguish the claim.

Insurers sometimes exploit the post-departure billing timing to deny claims. If this has happened to you, cite the date of admission against the date your employment ended — if admission predates the end of employment, the rejection has no basis.

The TPA arrangement under a group policy

Group policies often use TPAs appointed by the employer, which may differ from the TPA network you would use under an individual policy with the same insurer. The same IRDAI TPA obligations apply: the TPA must respond to pre-authorisation requests within one hour, must provide written reasons for rejections, and must not apply exclusions not found in the master policy.

If you are transitioning hospitals or seeking second-opinion treatment, verify in advance whether the treating hospital is empanelled under the group policy's TPA network — this may differ from the insurer's standard hospital network.

Portability rights on leaving a job

Under IRDAI portability regulations, when you leave an employer-sponsored group policy, you are entitled to port your coverage to an individual health policy with any insurer while retaining credit for the waiting period already served. If your group policy covered pre-existing conditions and you had been insured for 2 years, you carry that waiting period credit to your new individual policy.

The portability application must be made at least 45 days before the group policy lapses (i.e., before your last day of employment, or during the COBRA-equivalent continuation window). Missing this window forfeits the portability right and means you start fresh with a new individual policy and new waiting periods.

Documents for a group health insurance claim

• Master policy schedule and wording (request from HR if not provided)
• Employee ID or employment confirmation letter covering the hospitalisation date
• Hospital bills, discharge summary, treating physician's notes
• Pre-authorisation correspondence with the TPA
• Group policy certificate or benefit card issued to you

How to appeal a rejected group health claim

1. Obtain the master policy and compare it against the rejection reason. If the exclusion cited is not in the master policy, document the discrepancy.
2. Write to both your employer's HR/benefits team and the insurer's Grievance Redressal Officer. The employer has a contractual relationship with the insurer and can often escalate more effectively than an individual employee.
3. File on IRDAI IGMS. Group insurance claim rejections are within IRDAI's purview.
4. Escalate to the Insurance Ombudsmanfor claims up to ₹30 lakh. Group policy disputes from the beneficiary's perspective are within the Ombudsman's jurisdiction.