Can an insurer reject my claim for depression by calling it a lifestyle issue?

No. The Mental Healthcare Act 2017 mandates that mental illnesses must be treated as medical conditions, not lifestyle choices or exclusions.

What is the 30 day rule for insurance grievances?

If an insurer does not resolve your internal complaint within 30 days, you have the legal right to escalate to the Ombudsman.

Does the Insurance Ombudsman charge a fee for mental health cases?

No, the Insurance Ombudsman service is completely free for all policyholders and does not require hiring a lawyer.

Is therapy covered under my standard health insurance plan?

Standard plans usually cover IPD (hospitalization). Therapy (OPD) is only covered if your specific policy includes an OPD benefit or add-on.

What if my claim is rejected due to missing documents?

Insurers cannot reject claims solely for missing paperwork if the medical facts are clear. You can resubmit the missing documents and appeal.

Can I claim for a pre-existing mental health condition?

Yes, but only after the standard waiting period (usually 2 to 4 years) has passed, provided you disclosed it at purchase.

Mental Health Grievance Cell: Filing a Claim Appeal in India

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Mental Health Grievance Cell: What to do if your claim is denied

Your mental health claim cannot be rejected just because it isn't a physical injury; here is how to fight back using the law.

4 min read

OneAssure Team

April 13, 2026

Need advice tailored to you?

Looking for the right plan? You don't have to guess. Let us compare the fine print for you and give you an unbiased recommendation.

Need advice tailored to you?

Looking for the right plan? You don't have to guess. Let us compare the fine print for you and give you an unbiased recommendation.

Your claim for mental health treatment is not a favor

You have just been discharged after a week of treatment for severe clinical depression. The hospital bill is ₹1.8 lakh. You feel a bit better until the TPA desk hands you a rejection letter. The reason? Mental illness is not covered. This is not just frustrating. It is illegal. Since the Mental Healthcare Act of 2017 came into force, every insurer in India is legally bound to treat mental illness exactly like physical illness. If your policy covers a heart condition, it must cover bipolar disorder or anxiety too. No excuses. No hidden fine print. No discrimination. If you are a 28 year old professional paying your premiums on time, you have the law on your side. Do not let a generic rejection letter be the final word.

Why insurers still say no to mental health

Most rejections happen because of old systems. Many insurance companies still use software from the early 2000s that automatically flags psychiatric diagnoses as exclusions. Another common reason is the confusion between OPD and IPD. Most standard health insurance plans in India only cover IPD, which means you must be hospitalized for at least 24 hours. If you are only going for weekly therapy sessions (OPD), your claim might be rightfully denied unless you have a specific OPD add-on. However, if you were admitted to a hospital for a mental health crisis and the insurer still says no, they are likely violating Section 21(4) of the Mental Healthcare Act. They might also try to call it a pre-existing condition (PED). While they can apply a waiting period of 2 to 4 years for PEDs, they cannot reject the claim forever if you disclosed your history while buying the policy. Recent changes have even made insurance more affordable by removing the 18% GST on individual health policies, but that does not mean insurers can cut corners on claims.

Step 1: The Internal Grievance Redressal Cell

Your first fight starts inside the insurance company. Every insurer must have an internal Grievance Redressal Cell. You need to write a formal appeal letter to their Grievance Redressal Officer (GRO). Do not just call the customer care number. Send an email. Be firm. State clearly that under the Mental Healthcare Act 2017, mental health must be treated on par with physical health. Mention that your claim was for a legitimate medical necessity. Attach your doctor's certificate and the discharge summary. In India, insurers are now required to have a three member Claim Review Committee. This committee must include at least one medical professional to double check every rejection. Your appeal forces this committee to look at your case again. They have 15 days to respond to you. If they stay silent for 30 days, you move to the next level.

Step 2: Escalate to IRDAI Bima Bharosa

If the insurer ignores you or gives a vague reply, use the Bima Bharosa portal. This is the official oversight tool of the IRDAI. It was formerly known as IGMS. When you register a complaint here, the regulator sees it. The insurer gets a notification that is tracked by the government. You will need your previous complaint reference number from the insurer to prove you tried to resolve it internally first. OneAssure users often find that having a clear digital trail of these complaints is the best way to ensure the insurer takes the case seriously. The Bima Bharosa portal allows you to track your status in real time and ensures the company cannot just sit on your file forever. It brings transparency to a process that often feels like a black hole.

Step 3: The Insurance Ombudsman is your free judge

If Bima Bharosa does not solve it, the Insurance Ombudsman is your final stop before a court. This is a free service. You do not need a lawyer. There are 17 Ombudsman centers across India, from Delhi to Kochi. You can approach them if the claim amount is less than ₹50 lakh. The Ombudsman has the power to award compensation for the claim and even for the mental harassment you faced. Recently, the rules were updated to allow compensation up to ₹1 lakh for mental agony caused by the insurer. When you stand before the Ombudsman, focus on the medical facts. Show that the treatment was for a recognized disorder under the MHA 2017. If the insurer claims you missed some minor paperwork, point out that IRDAI rules forbid rejecting claims on technicalities if the medical necessity is clear.

Building a bulletproof claim file

To win an appeal, your documentation must be perfect. Young professionals often make the mistake of only keeping the final bill. You need the psychiatrist's consultation notes from before the admission. You need a clear diagnosis using ICD-10 or DSM-5 codes. Ensure your doctor provides a certificate stating that hospitalization was essential for your safety or recovery. If you are challenging a PED rejection, gather records that show you were stable or that the condition was managed. Insurers cannot reject your claim just because you had a minor anxiety episode five years ago if it was not relevant to the current admission. Keep every email, every acknowledgement slip, and every rejection letter in one folder. A strong paper trail is your best weapon against a denied claim.