What should I do if my health insurance claim is denied?

A person whose health insurance claim is rejected in Pakistan should obtain the insurer's reasoned written decision, check the policy wording and preserve medical and payment records before choosing a complaint or legal remedy. An insurer's rejection is not necessarily lawful merely because a claims officer cites "policy exclusion," but a policyholder also cannot assume every medical expense is covered. The correct result depends on the actual insured event, waiting period, sum insured, exclusions, disclosure obligations and any conditions that had to be satisfied. The Insurance Ordinance, 2000, the applicable policy and SECP's insurance framework provide the legal starting point.

Obtain the complete policy

Request the signed schedule, full terms and conditions, endorsements, benefit table, exclusions and renewal record. A hospital cashless-network brochure is not necessarily the legally controlling contract. Group medical insurance may be governed by a master policy held by the employer, with an individual membership certificate. Determine precisely who is insured, what benefit applies and whether the treatment fell within the period of cover.

Insist on written reasons

Ask the insurer to identify the exact exclusion or condition relied upon and explain which medical facts trigger it. A one-line message stating "not payable as per terms" gives the policyholder little basis to evaluate the result. Retain emails, claim portal screenshots, correspondence and any internal appeal outcome supplied. The claimant should not invent an exclusion's wording based on a call-centre discussion.

Confirm the insured treatment

Separate diagnosis, hospitalisation, procedure, investigations, medicines and post-discharge care. A policy may cover hospitalisation while excluding routine outpatient consultations or elective procedures. A claimant should check whether the disputed expense is actually classified correctly. A surgery may have been medically necessary even when scheduled in advance; the label "elective" does not always answer whether the policy's precise exclusion applies.

Medical necessity

An insurer may deny a treatment it regards as not medically necessary. Obtain the treating physician's explanation, clinical notes, admission record, imaging and discharge summary. The insurer should assess the treatment against the policy's definition and relevant medical evidence. A doctor describing a case as urgent can support a claim, but the medical record must demonstrate what made the intervention necessary. Mere disagreement between physicians may require independent medical review.

Pre-existing condition allegations

A denial may assert that the insured illness existed before coverage began. Examine how the policy defines pre-existing condition, what questions were asked and whether a waiting period or special endorsement applies. The fact that symptoms developed gradually does not by itself prove the customer knowingly concealed a diagnosis. The insurer should identify the relevant historical evidence and legal basis for denying this specific claim.

Waiting periods

Some medical policies defer coverage for specified illnesses, maternity benefits or other treatments after commencement. The claimant should calculate the actual dates, renewal continuity and any waiting period waived under employer group cover. The insurer should not apply a newly introduced waiting period retroactively without examining the agreed renewal terms. The exact period and circumstances matter more than the general description of the illness.

Network hospitals and preauthorisation

Cashless arrangements may require use of designated hospitals or advance approval for certain procedures. Check whether emergency treatment has different conditions and whether the insured was realistically able to obtain approval. A policyholder's failure to follow an applicable claim procedure can affect entitlement, but procedural noncompliance should be evaluated under the actual terms and evidence of prejudice where law makes that relevant.

Claim notification deadlines

Policies often set a period for notifying loss and submitting bills. Record when the treatment occurred, when the insurer was informed and why any delay arose. An emergency admission may involve practical obstacles. An insurer should not invent a notice requirement absent from its contract. A late notification issue should be distinguished from a substantive exclusion of the medical condition.

Bills and payment records

Submit original invoices or authenticated electronic records, itemised treatment bills, receipts and evidence of actual payment. A hospital estimate is not necessarily proof of expense incurred. If the hospital collected payment from an employer or another insurer, identify the actual amounts. The claimant should not seek reimbursement twice for the same cost or submit fabricated charges.

Sum insured and sublimits

A medical policy may impose an overall annual limit, per-disease limit, room category limit, co-payment or deductible. These conditions should be applied according to the agreed schedule. A claim within the overall sum insured can nevertheless exceed a particular covered-benefit limit. Ask for a numerical reconciliation showing payable charges and each deduction rather than accepting an unexplained partial settlement.

Employer-sponsored coverage

Where a group plan is provided through employment, obtain the relevant employer schedule and certificate. The employer may have separate contractual or statutory obligations beyond the insurer's coverage. A denial under group insurance does not automatically extinguish an employer's independent legal duty to reimburse medical expenses. The worker should distinguish the insurer's policy liability from employment service rules and company benefits.

Internal complaint and reconsideration

First submit a structured complaint to the insurer's designated grievance function with policy number, treatment dates, precise disputed condition and relevant documents. Ask for a reconsideration decision in writing. Preserve the filing date and response. A new medical opinion or overlooked endorsement may resolve the matter. Internal review can be useful but should not be assumed to extend all external statutory deadlines.

Federal Insurance Ombudsman

Pakistan has a Federal Insurance Ombudsman mechanism addressing relevant insurance grievances within its jurisdiction. The claimant should examine which disputes the office can hear and any requirement concerning initial insurer representation. Parallel proceedings can affect jurisdiction and should be disclosed. The ombudsman is not automatically empowered to award every type of commercial damages claimed in ordinary litigation.

Small Disputes Resolution Committees

Section 117 of the Insurance Ordinance, 2000 provides for Small Disputes Resolution Committees, with eligibility and procedure governed by applicable rules and amendments. SECP's official guidance describes the mechanism and complaint handling. Monetary limits and procedures should be checked in the current rules. A consumer should not file simultaneously before several forums assuming each will independently award the same amount.

Insurance Tribunal and court

The Insurance Ordinance contains provisions concerning Insurance Tribunals and specified jurisdiction. The nature of the case and statutory allocation matter. A contractual claim may require tribunal proceedings rather than an ordinary consumer suit, depending on law. The claimant should select the competent forum and calculate limitation, particularly where substantial sums or contested coverage principles are involved.

An emergency surgery example

A patient is admitted for an obstructed hernia after acute symptoms and undergoes urgent surgery. The insurer refuses payment as an elective or pre-existing condition. The claimant should obtain emergency admission notes, treating physician explanation and policy terms. The outcome depends on the medical evidence and actual exclusion, not merely the insurer's label or the claimant's understandable concern.

A group-policy example

An employee receives a cashless card but the hospital demands payment because the network insurer has not authorised the procedure. The employee should verify whether preauthorisation was required, when it was requested and whether emergency exceptions apply. Employer HR records can assist. The individual should distinguish the insurer's claim determination from any separate entitlement under the employment contract.

Opinion and recommended course

A denied health insurance claim should be challenged through a documented comparison of medical facts and contractual coverage. Obtain specific written reasons, organise bills and treatment evidence and apply to the competent insurer complaint, ombudsman, committee or tribunal process. A blanket exclusion assertion is not conclusive; neither is proof that treatment was expensive or medically desirable.

Principal authorities: Insurance Ordinance, 2000, including sections 117 and 122 as applicable; Insurance Rules, 2017, updated March 2025; Small Dispute Resolution Committees (Constitution and Procedure) Rules, 2015 and amendments; policy terms; SECP insurance complaint guidance: https://www.secp.gov.pk/faq/possible-scenarios-of-delayed-complaint-settlement/.