Question 1

Is the claim analysis really free? What's the catch?

Accepted Answer

Yes, completely free. We believe every policyholder deserves to know whether their claim was handled fairly — before paying anyone anything. Upload your documents and get a full AI-powered analysis at no cost. We may introduce paid premium features in the future, but the core analysis will always remain free.

Question 2

Which types of insurance claims do you support?

Accepted Answer

Currently we support health insurance claims — including hospitalisation (cashless and reimbursement), OPD claims, and critical illness claims. We cover all major Indian insurers and TPAs. Support for other lines of insurance (motor, life, travel) is on our roadmap.

Question 3

Do you handle the recovery yourself, or do I have to do it?

Accepted Answer

We handle the analysis and strategy; you submit the actual grievances. fairClaims gives you a personalised recovery plan, draft grievance letters addressed to the insurer's GRO, and — if needed — a ready-to-file Ombudsman complaint. You're always in control, and we walk you through every step in plain language.

Question 4

What documents do I need? I don't have everything.

Accepted Answer

The most useful documents are: your discharge summary, itemised hospital bills, the insurer's claim settlement or rejection letter, and your policy schedule. If you're missing some, upload what you have — our system is designed to work with partial documentation and will flag exactly what's needed to strengthen your case.

Question 5

My claim was rejected months ago. Is it too late?

Accepted Answer

Probably not. Under IRDAI regulations you can file a grievance with the insurer's Grievance Redressal Officer (GRO) at any time after rejection. If the GRO doesn't resolve it, the Insurance Ombudsman accepts complaints up to one year from the date of the insurer's final rejection letter. We'll tell you exactly where you stand based on your case timeline.

Question 6

How long does the dispute process typically take?

Accepted Answer

A GRO complaint must be acknowledged within 3 days and resolved within 15 days under IRDAI rules. If it escalates to the Insurance Ombudsman, hearings are typically scheduled within 30–90 days and awards issued within 3 months of the hearing. Consumer Forum cases can take longer — 6 to 18 months — but are an option for larger amounts.

Question 7

What are the most common reasons health insurance claims are rejected?

Accepted Answer

The most frequent grounds Indian insurers cite are: (1) alleged non-disclosure of pre-existing conditions, (2) treatment falling under a policy exclusion, (3) incomplete or missing documentation, (4) the procedure not matching the admitted diagnosis, and (5) charges exceeding 'reasonable and customary' benchmarks. Most of these are challengeable — especially when the insurer applies them broadly or without specific policy language to back them up.

Question 8

My insurer says I didn't disclose a pre-existing condition. Can I still fight back?

Accepted Answer

Yes, and this is one of the most frequently overturned rejections. The insurer must prove (a) that the condition existed before the policy, (b) that you knew about it, and (c) that it is materially related to the current claim. If the condition was undiagnosed, unrelated to your hospitalisation, or if you are past the waiting period, the rejection is often legally invalid. Our analysis will check all three criteria against your documents.

Question 9

What does 'reasonable and customary charges' mean and how does it affect my payout?

Accepted Answer

'Reasonable and customary' (also called 'standard charges' or 'package rates') is the amount the insurer decides is the going rate for a procedure in your city tier. If your hospital billed more, the insurer may settle only the benchmark amount. This is legitimate in principle, but insurers sometimes apply stale or geographically wrong benchmarks. If you believe the benchmark used is wrong, we can help you document the correct local rates and contest the deduction.

Question 10

Can I contest a cashless denial at a non-network hospital?

Accepted Answer

A cashless denial at a non-network hospital is not a claim rejection — it simply means you pay upfront and claim reimbursement afterwards. Under IRDAI's cashless regulations, even non-network emergency admissions are covered subject to your policy terms. If your insurer later refuses the reimbursement citing 'non-network', that is a separate and challengeable rejection.

Question 11

Will challenging my claim affect my future coverage or renewal?

Accepted Answer

No. Filing a grievance is your statutory right under the IRDAI (Protection of Policyholders' Interests) Regulations. An insurer cannot legally refuse renewal, increase your premium, or flag your policy as 'problematic' because you exercised your right to dispute a settlement. If an insurer does this, that itself is a regulatory violation you can escalate.

Question 12

What is IRDAI and what rights does it give me?

Accepted Answer

IRDAI (Insurance Regulatory and Development Authority of India) is the statutory regulator for all insurance in India. It mandates that every insurer have a Grievance Redressal Officer (GRO), publish turnaround times, provide written reasons for every rejection, and allow you to escalate unresolved disputes to the Insurance Ombudsman — free of charge. Many policyholders are unaware of these rights, which is exactly why insurers often get away with poor settlements.

Question 13

What is the Insurance Ombudsman and when should I approach them?

Accepted Answer

The Insurance Ombudsman is a free, quasi-judicial authority set up by the Government of India to resolve disputes between policyholders and insurers. You can approach the Ombudsman after: (a) the insurer's GRO rejects your complaint, or (b) 30 days have passed with no resolution, or (c) you're dissatisfied with their response. Ombudsman awards are binding on insurers up to ₹50 lakh. There is no fee to file a complaint.

Question 14

What is a TPA and why do they sometimes reduce claim amounts?

Accepted Answer

A TPA (Third-Party Administrator) is a company licensed by IRDAI to process claims on behalf of insurers. TPAs apply the insurer's internal benchmarks for 'reasonable and customary' charges and check documentation compliance. Reductions by a TPA are not final — they can be challenged by filing a grievance with the insurer's GRO, who is legally required to review TPA decisions independently.

Question 15

Is my medical and financial information safe?

Accepted Answer

Yes. We use 256-bit AES encryption — the same standard used by banks — for all data at rest and in transit. Your documents are never sold, shared with insurers, or used to train AI models. You can request complete deletion of your data from your account at any time, and we will purge it within 7 days.

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