Health Insurance Complaint Against Niva Bupa Health Insurance for Rejection of Legitimate Claim

chetanchauhan2001 · 19 January 2026

Dear Team

I am writing to formally lodge a complaint against Niva Bupa Health Insurance regarding repeated wrongful rejection of my health insurance claim, which has caused me severe mental harassment and financial distress. Below are the details of my case:

Policy Details:

Policy Number: 35771858202500

Client ID: 2004430496

Insurer: Niva Bupa Health Insurance

Type: Individual Health Insurance (Ported from Navi Health Insurance)

Policy Start Date: 30 January 2025

1* Case Details:

* Hospital Admission & Initial Claim:

* Date of Hospitalization: 4 August 2025

Hospital: Venkateshwar, Dwarka

* Reason: Medication revision related to migraine

* Claim ID: 1211500

* Issue: I submitted a cashless claim under my individual policy, which was rejected by Niva Bupa citing “policy terms and conditions” and was asked to submit a reimbursement claim instead. I complied and sent the required documents via email

2* Corporate Policy Claim:

Coincidentally, I also submitted a claim under my corporate health insurance policy, which was approved by the corporate insurance company (Claim ID: 2000201539). The company deducted non-payable items, which is acceptable

3* Reimbursement Claim under Individual Policy:

Amount Claimed: ₹3,474 (covered under my addon rider in the individual policy)

Claim ID: 2381798

Issue: Niva Bupa rejected the reimbursement claim, stating that I did not intimate the company prior to admission, even though:

* The company itself instructs customers to submit reimbursement claims.

* They fail to provide clear instructions at the time of hospitalization.

* There is inconsistency and delay in their claim handling and communication.

Problems Faced:

* Multiple claim rejections despite valid coverage.

* Lack of guidance from Niva Bupa during the claim process.

* Mental harassment and financial stress due to continuous delays over 5 months.

* Repeated misinformation and contradictory instructions from the insurance company

Request:

* Immediate intervention by IRDAI / Consumer Court to ensure my reimbursement claim of ₹3,474 is processed.

* Compensation for the mental harassment and financial inconvenience caused by the repeated wrongful claim rejection.

* Appropriate action against Niva Bupa Health Insurance for mishandling claims, misleading instructions, and non-compliance with policy terms.

Attachments:

All claim letters

Hospital documents

Policy copy

All email communications

I kindly request your intervention to ensure justice and timely settlement of my claim.

Chetan
9717579222

TeamMember · 6 March 2026

Hello @chetanchauhan2001

We have review the details and suggest you to first send a legal notice to the Niva Bupa Health Insurance and ask them to approve the claim.

Avinadal · Wednesday at 11:16 AM

Dear Sir/Madam,

I am writing to formally escalate my grievance to the senior management/grievance redressal authority of Niva Bupa Health Insurance Company Limited regarding the **repeated, arbitrary and unjustified rejection of my reimbursement claim**, despite my having strictly followed the instructions provided by Niva Bupa’s own Customer Care representatives and having submitted the additional document specifically requested by your representative.

This matter is no longer merely a claim dispute. It concerns the **inconsistent advice provided by Niva Bupa, the manner in which my claim has been adjudicated, and the failure to properly address the documents and circumstances placed on record by me.**

### POLICY & CLAIM DETAILS

**Policy No.:** 31655679202401
**Claim ID:** 3732634
**Claim Amount:** ₹1,33,696/-
**Hospital:** Max Super Speciality Hospital, Vaishali
**Date of Admission:** 24 July 2026
**Date of Discharge:** 27 July 2026
**Reimbursement Claim Submitted:** 29 July 2026
**Doctor Treated Certificate Submitted:** 19 August 2026
**Latest Rejection:** 1 September 2026

### 1. I RELIED UPON THE INSTRUCTIONS OF NIVA BUPA CUSTOMER CARE

I was admitted to Max Super Speciality Hospital, Vaishali on **24 July 2026** and discharged on **27 July 2026**.

During the course of my hospitalization/discharge process, I contacted Niva Bupa Customer Care and specifically sought guidance regarding the claim/payment process.

I was clearly advised by your Customer Care representative that I could **pay the hospital bill, take discharge and thereafter submit a reimbursement claim**.

I relied upon this information because it was provided by an authorised representative of Niva Bupa.

Accordingly, I paid the hospital expenses and took discharge. Thereafter, as instructed, I submitted my reimbursement claim on **29 July 2026**.

It is therefore completely unreasonable and unfair that Niva Bupa subsequently rejected the reimbursement claim by relying upon the very circumstances which I had specifically discussed with your Customer Care team before submitting the claim.

### 2. I WAS AGAIN GIVEN A SPECIFIC ASSURANCE ON 19 AUGUST 2026

After the initial rejection, I once again contacted Niva Bupa Customer Care on **19 August 2026**.

During this interaction, **Ms. Nisha**, representing Niva Bupa Customer Care, specifically instructed me to obtain a **Doctor Treated Certificate (DTC)** from the hospital.

I was informed that after submission of the DTC, my claim would be processed/approved.

Once again, I relied upon the representation made by Niva Bupa's authorised representative.

I immediately approached Max Super Speciality Hospital, obtained the Doctor Treated Certificate and submitted the same to Niva Bupa on **19 August 2026** through the designated document submission channel.

### 3. DESPITE COMPLYING WITH YOUR INSTRUCTIONS, THE CLAIM WAS AGAIN REJECTED

Shockingly, despite my complying with the specific requirement communicated by your Customer Care representative, Niva Bupa again rejected my claim on **1 September 2026**, citing essentially the same admission-related reason.

This raises a fundamental question:

**If submission of the Doctor Treated Certificate was not going to resolve the alleged deficiency, why was I specifically instructed to obtain and submit it with an assurance that my claim would be processed/approved?**

I have complied with every instruction communicated to me by Niva Bupa.

I cannot reasonably be expected to suffer a financial loss of **₹1,33,696/-** because Niva Bupa's own representatives provided instructions which were subsequently disregarded by the claims/grievance team.

### 4. REPETITIVE REJECTION WITHOUT PROPER CONSIDERATION OF THE RECORD

The latest rejection appears to merely repeat the earlier reason without adequately addressing:

* My actual medical circumstances and hospitalization;
* The hospital records;
* The Doctor Treated Certificate submitted on 19 August 2026;
* The instructions given to me by Niva Bupa Customer Care;
* My reliance upon those instructions;
* The reason why submission of the DTC did not resolve the alleged deficiency; and
* The exact contractual/policy provision relied upon for rejection.

A mere repetition of the rejection reason does not adequately address the material facts and documents submitted by the policyholder.

If Niva Bupa maintains that my admission was not in accordance with a particular requirement/protocol, I require Niva Bupa to clearly identify:

**(a)** the exact policy clause relied upon;
**(b)** the precise factual basis for invoking that clause;
**(c)** the documents/evidence relied upon; and
**(d)** why the Doctor Treated Certificate and other medical records do not satisfy or otherwise address the alleged deficiency.

### 5. DEMAND FOR FRESH AND INDEPENDENT REVIEW

I hereby request the senior grievance/claims authority to conduct a **fresh, independent and unbiased review** of Claim No. 3732634.

I specifically request that the following be reviewed:

1. The complete claim file and claim adjudication notes;
2. My hospitalisation records and discharge documents;
3. The Doctor Treated Certificate submitted on 19 August 2026;
4. The complete communication history relating to my claim;
5. The Customer Care call records/recordings concerning my conversations with Niva Bupa;
6. In particular, the interaction with **Ms. Nisha on 19 August 2026**;
7. The exact policy clause under which the claim has been rejected; and
8. The basis on which the same rejection ground was maintained even after submission of the specifically requested DTC.

### 6. REQUEST FOR A SPEAKING AND REASONED DECISION

I specifically request that Niva Bupa refrain from issuing another generic or repetitive rejection communication.

If the claim is still proposed to be rejected, I require a **detailed, reasoned and speaking decision** setting out:

* The exact policy wording/clause;
* The applicability of that clause to my particular case;
* The medical/claim documents relied upon;
* The reason for disregarding the Doctor Treated Certificate;
* The reason the instructions given by Niva Bupa Customer Care were not considered;
* The reason the claim remained inadmissible despite my complying with the additional document requirement communicated by your representative.

### 7. WITHOUT PREJUDICE – RIGHTS RESERVED

This communication is being submitted **without prejudice to my rights and remedies available under the applicable insurance laws, regulations, policy terms and grievance-redressal mechanisms.**

In the event that Niva Bupa fails to provide a satisfactory and properly reasoned resolution, I reserve my right to escalate the matter before the **appropriate regulatory and insurance grievance-redressal authorities, including the Insurance Ombudsman and other competent forums**, as may be available to me.

I will also place on record the complete chronology of events, including the instructions provided by Niva Bupa Customer Care and my compliance with those instructions, before the appropriate authority.

### 8. FINAL REQUEST

I have acted in good faith throughout this entire process.

I contacted Niva Bupa for guidance, followed the instructions given by your representatives, paid the hospital expenses, submitted the reimbursement claim, obtained the additional Doctor Treated Certificate specifically requested by your representative, and submitted the same within the required process.

Despite this, my legitimate reimbursement claim of **₹1,33,696/-** has been repeatedly rejected on substantially the same ground without properly addressing the material facts and documents.

I therefore request Niva Bupa's senior authority to **reopen the claim, conduct a fresh review and reconsider the reimbursement claim on merits.**

Please treat this email as a **formal grievance escalation and request for senior-level intervention**.

I expect a written, reasoned and final response at the earliest, rather than another repetitive rejection communication.

**Claimant/Policyholder:** Avdhesh
**Mobile:** 9555345164
**Policy No.:** 31655679202401
**Claim ID:** 3732634
**Claim Amount:** ₹1,33,696/-

Regards,
**Avdhesh**
Mobile Number:- 9555345164
Mail Id:- avdhesh.nadal@gmail.com

Health Insurance Complaint Against Niva Bupa Health Insurance for Rejection of Legitimate Claim

chetanchauhan2001

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Attachments

TeamMember

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Avinadal

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