INSURANCE MITRA

Claim rejection case file

Tell us what happened. We'll check your rejection against IRDAI rules before you write a single word to the insurer.

We're sorry for your loss. Tell us what the insurer said, and we'll check it against IRDAI's rules for death claims before you respond.

Tell us a bit about yourself, then go through the checklist below. We'll use this to (1) generate a personalized recommendation on what type of policy and cover to look for, and (2) give you a written disclosure summary to hand an insurer once you've picked one. If you have no health conditions to disclose, just check the box at the top of the checklist — you don't need to leave everything blank and hope that counts.

Standard chronic conditions (always ask about these)
Often-missed findings insurers use later (the ones that get weaponized)
Post-COVID / recent symptoms (frequently undisclosed because people don't think of them as conditions)
History & records to gather (insurer cannot claim ignorance of these)

Government-backed health coverage that exists alongside any private policy you may have. There are two separate routes into Ayushman Bharat — most of this needs no agent, no premium, and no paperwork beyond an Aadhaar card.

GOVT
SCHEME

Ayushman Bharat — PM-JAY (low-income / SECC families)

₹5 lakh/family/year No premium, ever No waiting period Pre-existing diseases covered day one

This is the original, larger Ayushman Bharat scheme — it covers over 12 crore families nationwide and gives ₹5 lakh per family per year for hospital treatment, completely free, at any empanelled public or private hospital. Unlike most insurance, it covers pre-existing conditions from day one with no waiting period at all.

Who qualifies: eligibility is based on the 2011 Socio-Economic Caste Census (SECC), not your current income. You're likely covered if your household fits any of these:

  • Rural households: no adult member aged 16–59, headed by a woman with no adult male member in that age range, has a disabled member with no able-bodied adult, lives in a single-room kutcha house, or is a landless household dependent on manual labour
  • Urban workers: street vendors, domestic helpers, rickshaw or cart pullers, construction workers, masons, painters, plumbers, welders, security guards, sweepers, or similar laborers in the unorganised sector
  • SC/ST households, bonded labourers, manual scavengers, primitive tribal groups, and similarly vulnerable groups are automatically included
  • ASHA workers, Anganwadi Workers, and Anganwadi Helpers are also covered as of a 2026 expansion

Who's generally excluded: households where any member pays income tax, or has a regular (non-contractual) government job, typically don't qualify for this particular route — though the 70+ senior citizen scheme below has no such restriction.

How to check and apply:

  • Use the "Am I Eligible" tool on the official portal (pmjay.gov.in) or the Ayushman App with your mobile number, name, and state
  • Or visit your nearest empanelled hospital or Common Service Centre (CSC) and ask for the Ayushman Mitra help desk — bring your Aadhaar card and ration card
  • Call the toll-free helpline 14555 if you're unsure where to start
  • If you're SECC-listed, you don't "apply" in the usual sense — you're already entitled, you just need to verify identity to get your card issued
GOVT
SCHEME

Ayushman Bharat — Senior Citizen Scheme (Vay Vandana, 70+)

₹5 lakh/year cover No income limit No waiting period Aadhaar only

Every Indian citizen aged 70 and above is eligible for ₹5 lakh of free hospital coverage per year, regardless of income or existing private insurance — this is separate from the SECC-based scheme above and doesn't require meeting any of those low-income criteria. It was expanded nationwide in 2024, and as of mid-2026 covers roughly 6 crore senior citizens. If your family already has a PM-JAY card from the SECC route, a 70+ member gets an additional ₹5 lakh on top of that, just for themselves. Coverage starts immediately — there is no waiting period for any disease or treatment.

How to apply:

  • Keep your Aadhaar card ready — it's the only document needed for enrollment.
  • Visit the PM-JAY portal, the Ayushman App, or your nearest Common Service Centre (CSC) to register.
  • If your spouse is also 70+, you don't need a separate application — add them as a family member on the same enrollment using the "Add Member" option.
  • Once approved, you'll receive a distinct Ayushman Vay Vandana card for cashless treatment at empanelled hospitals.

One important catch: if you (or the senior citizen in question) already use a government scheme like CGHS, ECHS, or CAPF health coverage, you must choose between that scheme and PM-JAY — you can't claim both at once, and switching to PM-JAY from one of these is a one-time, non-reversible choice. If you have private health insurance or ESI coverage instead, there's no conflict — you can hold PM-JAY alongside either of those.

A note on accuracy

Government scheme rules can change with new notifications, and some states (Karnataka, Tamil Nadu, Rajasthan, Andhra Pradesh, Telangana, and others) run their own expanded eligibility lists on top of the central SECC data. Always confirm current details on the official PM-JAY portal or by calling the Ayushman Bharat helpline before relying on this for a real decision.

Straight answers about how this tool works, what it costs, and what it can't do for you.

Most of it, yes. Checking your claim against the rules, getting a score, the disclosure checklist, the government schemes guide, and the free life/death claim letter template all cost nothing. Two things are paid: the AI-drafted grievance letter for a health claim, and the AI policy recommendation — both a one-time ₹99, because both require a real AI request that costs us money to generate.

No. This tool checks your situation against published IRDAI regulations and gives you an honest read on how strong your case looks, and drafts a letter you can send. It is not a substitute for a lawyer, and for large or complex disputes you may still want one. For most ordinary claim rejections, though, the IRDAI Grievance process and the Insurance Ombudsman are designed to work without a lawyer at all — that's the whole point of those channels.

No — the score and the underlying rule it's based on come from a fixed set of rules built on actual IRDAI regulations (the 5-year health moratorium, the 3-year life insurance contestability period, the rule that a missing nominee doesn't void a claim, and others). The AI never decides your score. Its only job is writing the grievance letter in plain, formal language once the score and the legal reasoning have already been worked out.

No login, no password, no account. Your case stays attached to your current browser for the length of your session so the tool can walk you through the steps, but there's nothing for you to sign up for or remember.

The details you enter (insurer, policy, rejection reason, your answers) are stored only to generate your score and letter, and aren't tied to your name or any login. Nothing is sold or shared with insurers, agents, or advertisers.

Not necessarily. This tool deliberately gives some rejections a low score when the insurer's exclusion is genuine and clearly worded — for example, a clearly excluded cosmetic procedure. Fighting a valid exclusion wastes your time. A low score is the tool being honest with you, not a sign it isn't working.

Every verdict includes the next legal step: if the insurer's Grievance Redressal Officer doesn't respond in 15 days, you can file on IRDAI's Bima Bharosa portal. If that doesn't resolve it within 30 days, the Insurance Ombudsman can settle disputes up to ₹50 lakh — free of charge, binding on the insurer, and without needing a lawyer.

By design. The recommendation tells you what type of cover, sum insured, and riders suit your situation — not which company to buy from — so the advice stays neutral and isn't influenced by which insurer might pay for a mention.

Have feedback or found something broken?

Tell us what worked, what didn't, or what's missing — this goes straight to the person building the tool.