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U**Hi Everyone, long post – writing down my story on how I fought and won the insurance case against Niva Bupa.**
Early last year, I fell seriously ill with a persistent high fever and all. Initially, I sought treatment at a local clinic, but my condition did not improve. So, I consulted doctors at a some bigger hospital, yet even after following their prescribed medications, my fever was not going away.
Given my worsening health and the lack of improvement, I made the difficult decision to travel to my home city, where my family could provide necessary support during my illness. Despite my poor health, I took a flight, where my family picked me up and took me directly to a hospital. **I was admitted and diagnosed with typhoid, for which I received inpatient treatment.**
# Claim Submission and Rejection by Niva Bupa
After my discharge, **I submitted a medical claim of over ₹1,00,000 to Niva Bupa**. Niva Bupa conducted an offline verification with the hospotal. They also requested physical copies of my medical records, which I sent to their office. Throughout the process, I remained transparent. But, despite multiple follow-ups, Niva Bupa remained unresponsive and delayed processing my claim. After a couple of months, I finally received an email informing me that **my claim had been rejected underpolicy clauses related to misrepresentation and fraud.** This was a shocking and baseless accusation.
# Grievance Redressal Process
I escalated the matter to **Niva Bupa’s Grievance Redressal Office (GRO)**. Their primary objection was that I had chosen to receive treatment outside Delhi. I explained my reasons, emphasizing that my condition was serious, I had already tried treatment in Delhi, and my family could only take care of me elsewhere. Despite my efforts, I received no response to my follow-up emails. So, after a month – I received a vague reply stating that the matter was under review.
Then after receiving no reply for a month – one day I finally received a response – **claim rejected again**, this time citing company guidelines, without any specific explanation.
# Escalation to IRDAI
Having exhausted Niva Bupa’s internal process, **I escalated my case to the Insurance Regulatory and Development Authority of India (IRDAI) via Bima Bharosa**. I provided a detailed explanation of why my claim denial was unfair.
When responding to IRDAI, **Niva Bupa changed their justification, now arguing that my hospitalization was primarily for diagnostic and evaluation purposes and was not necessary**. So, IRDAI did not provide a satisfactory resolution, and after months of delays and back-and-forth, I realized I had no choice but to approach the Insurance Ombudsman.
# Fighting My Case at the Insurance Ombudsman
So, I submitted a formal complaint to the Insurance Ombudsman, detailing every stage of my battle against Niva Bupa. I explained how their justifications had kept changing – from alleged fraud to unnecessary hospitalization – and how their decisions lacked any medical basis.
**I represented myself at the Ombudsman hearing, while Niva Bupa sent a lawyer. Since I knew my case inside out, I countered every weak argument they made, exposing the inconsistencies in their claims. The lawyer had no solid defense, as Niva Bupa’s reasoning kept shifting throughout the process.**
The Ombudsman **ruled in my favor**, forcing Niva Bupa to settle my claim.
**This entire ordeal lasted for almost a year**, causing significant stress. The constant delays, shifting justifications, and lack of accountability from Niva Bupa made it clear that their approach was meant to discourage claimants rather than provide fair resolutions. so, I feel it is very important to keep following 2-3 things in mind while fighting this :
* **Persistence is crucial:** without continuous follow-ups and escalations, the claim would have been lost.
* **Documentation is everything:** keeping detailed medical records, emails, and responses helped prove my case.
* **Self-representation can be powerful:** knowing your case well can be more effective than hiring a lawyer. (atleast at the level of insurance ombudsman, this is my opinion.)**So, to anyone out there fighting a case like this – don’t lose hope. Fight hard, and victory will be yours. All the best!**
**TL;DR:** I battled Niva Bupa for nearly a year after they unfairly rejected my insurance claim, first accusing me of fraud, then saying my hospitalization was unnecessary. Despite escalating through their grievance process and IRDAI, I got no resolution. Finally, I took my case to the Insurance Ombudsman, where I represented myself against their lawyer and won.
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UKudos man. That’s really something. I can understand situation like these could be really troublesome and can take a toll on you and your family. Did you get any compensation for your troubles?
Does it also mean that Niva Bupa is basically a corrupt and fraud insurer? They have tried to reject your claim falsely and on top of that the justification was delayed unnecessarily.
Also I would love to hear the exchanges between you and their lawyer. If you get some time, please entertain us.
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UI have not received any compensation for the mental anguish I had to endure. I believe this does not fall under the ambit of the Insurance Ombudsman, and as you can imagine, I was exhausted from all the back and forth. So, after receiving my claim amount, I did not follow up with the Ombudsman regarding this. Now, I’m unsure whether I should email the Ombudsman again now to pursue the ₹30,000 I had claimed for mental anguish or take the matter to consumer court and seek compensation there. **I’m also uncertain about how much I should ask for. My claim amount was approximately ₹1.2 lakhs.**
I don’t know if I can outright call Niva Bupa a corrupt insurer. My previous claims were processed smoothly, but those were for smaller amounts. So, I’m not sure – maybe any insurance company can pull a move like this if they want to, especially when the amount is bigg!. From now on, I will seek treatment only at network hospitals whenever possible. I believe this should reduce hurdles in the claim process.
Regarding My Exchange with the Lawyer
The lawyer began with a vague argument (I had expected Niva Bupa to come up with something new in the hearing, lol). He claimed that some details were missing from one of my reports. I asked him to specify which report so I could clarify with my doctor or the lab. Then, he shifted to arguing about my hospitalization, saying that my this count / that count in the lab reports appears normal which is something they had already mentioned in their emails for which I had replied them there. but nothing good came out of it.
I knew this was a weak and baseless argument. So, I told the Ombudsman and the lawyer: “If something had happened to me, who would have been responsible? You or the doctor? The doctor is the best authority to decide whether hospitalization is necessary, even if my fever subsides or my anythung in the lab test count appears normal. I had symptoms for weeks, and my doctor, using his best judgment, determined that hospitalization was required. and for this my doctore had already submitted a letter to Niva Bupa supporting this decision.”
At that point, the lawyer was speechless. He had no counterargument. I mean, this is very fucjing basic thing man, doctor will decide no whether I should be kept under observation or not. which Niva Bupa constantly refused to acknowledge.
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UI have come across another Niva Bupa issue [here](https://www.instagram.com/reel/DGhWSJXv4o0/?igsh=MTR2NHQ0NmR3a2RjMg==)
Might be of some interest to you.
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UHey quick doubt as i’m going to be stepping into similar situation as well.
1. In Ombudsman, do they cross verify the data you/ lawyer presents ie. do they put case on hold until they verify all details. Or is it like alloted 2 hours time for case hearing in which there is a FINAL verdict by the end of it?
2. Was it just you, the lawyer and judge?
3. Now that you’ve cleared it, any advice/ loopholes that can make claim much strongerWanted to know how long drawn and intricacies of the whole process.
Thank you for fighting!
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SQuestion: How much time and money did you spend fighting this case? Did it affect your work? Any way you can claim comp for mental anguish?
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UNo, I didnt’ spend a single ruppes from my side cause I fought it all alone. but the major investment was time.
I have invested around 10 months in this whole process. offcurse, it did affect my work. my job is very demanding and handling all this drama side by side was very challenging. and for me 1 lac rs amount is very big – It was some good % of my savings. I couldn’t have just let it go. I am thinking to sue them in consumer court but let’s see, will do it in some months. I am not sure tho- how much I should ask.
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UThanks for the detailed write up. Interesting read.
Was there any extra money spent during this process? Were those reimbursed too?
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UWe need people like you man, happy for you.
I hope you got good enough compensation as well for your stress and time wasted.
I am now regularly see that NIVA Bupa is not issuing claims. Better to avoid them in the coming when coming to any sort of insurances.
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UI have a query, can you sue them in high court for metal agony and delaying payments by giving false justifications?
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UYes, I think, I should. but being a working professional and my job is pretty hectic, it is going to be difficult. I think, I will go to consumer court atleast but in upcoming months, I will. currently my job is in peak hectic stage. lol.
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Bmore power to you I’m pretty pleased you managed to get your money compensated. I’m hoping you will follow up with suing them for your mental agony. Cheers!
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UExcellent result , well done as people usually give up. Thank you for sharing your experience and providing a template for othersin future
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PWas the legal fees and money coverer by nivs bupa or did you have to pay it out of your own pockets?
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UThank you for sharing. It gives people some hope against companies that are unfair in their dealings with customers.
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UGood work!!
But i have a question in such situations:
Are u compensated by them for wasting ur time upon the 1 lakh of ur actual claim? If so how much?
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SOp please spread this around in your groups. If, insurance Co rejects, anyone else goes thru this, then help them out with the process.
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UVery inspiring, thank you for sharing the process.
Your post was easy to read as well, I bet this clarity of communication helped when you represented yourself.
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UGood work OP, it shouldn’t have happened to you in the 1st place but it’s amazing you didn’t back down and put up a fair fight!
Ik this might not be the best place to ask, but I just started working and need to get health insurance for myself + whole family. My options are either Niva Bupa or Aditya Birla. My bank has a tie up w these two providers, but I can also go out and get insured by any other provider. I’m apprehensive of getting insurance because of all that’s happening around, people like us getting claims rejected while Saif Ali Khan gets his approved in 2 days, Luigi Mangione and all. But I have gotta get one cause my parents are aging.
My fam is pushing me to get an insurance and aren’t helping me with the process of choosing a provider. Is there any provider that actually isn’t a retard and has a filthy long process for claims only to end up rejecting it? -
UWhats the fing point of having insurance if its just another pain in the rear. !!??
I claimed 2.3 for a fracture to United india. They gave 1.5L only. 20k they reduced coz they said claim should have been cash less and not re-embursement. How am i responsible for it ??? Nowhere in policy doc it says something like this. -
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Uhey – could you share who to reach out to first after niva bupa declines claim after multiple escalations and claim reconsiderations? I’ve gone through grievance redressal with no success for the past 3 months.
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UYou can escalate complaint to IRDAI or Insurance Ombudsman. But – I would say first go to the IRDAI and then Insurance Ombudsman because it will add a trajectory to your case – you can argue that in front of the ombudsman.
And regarding official complaint email – I hope whatever issue you are facing and whatever communication you are having with Niva Bupa is through emails. You can just print them and attach in the supporting documents in your complaints moving forward. And if you have already escalate to grievance redressal of Niva Bupa – then you dont meed to write any other complaint emails to the insurance company as your grievance itself is a complaint.
All the best!!
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UI see, alright thank you.
In my case they haven’t outright rejected as per policy. They want a document from 2018 which doesn’t exist, but I’ve submitted a signed letter from my GP from 2025 that answers their queries. But they’re ignoring that and continuing to deny basis the non-submission of that document.
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UFrom Customer Care Team to Medical Team to Grievance Redressal Team to Internal Claims Samadhan Team. Now what next ??? Since it’s internal Claims Samadhan Team, email or contact number not provided. How to follow up? Through which Department?
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UNiva Bupa has an in-house claim settlement team, aiming for quick and efficient settlements that’s what company states but in reality, for months we go through never ending problems inspite of repeated followups. No one wants to understand and no one wants to read your mails. Company has standard stereotyped reply drafts and you keep on getting such vague irrelevant replies. More than the premium, even the delay in settling claims, brings interest in crores to the company.
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