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When Sunita’s husband was admitted to a private hospital for a heart procedure, the family felt relieved that they had a health insurance policy of ₹10 lakh. The hospital initiated a cashless claim, and the treatment began immediately.
When Sunita’s husband was admitted to a private hospital for a heart procedure, the family felt relieved that they had a health insurance policy of ₹10 lakh. The hospital initiated a cashless claim, and the treatment began immediately.
Two days later, the insurance company sent a short message:
“Claim rejected due to pre-existing disease not disclosed at the time of policy purchase.”
The family was shocked. The hospital bill had already crossed ₹3.2 lakh, and they were now being asked to arrange the entire amount themselves.
The insurer claimed that Sunita’s husband had a history of high blood pressure before purchasing the policy and had failed to disclose it.
Sunita insisted that the proposal form had been filled by the insurance agent, and no detailed medical questions had been explained to them.
Like many policyholders, they had signed where they were told to sign.
Health insurers frequently reject claims on grounds such as:
However, a rejection letter does not always mean the insurer’s decision is final.
Instead of paying the bill immediately and giving up, Sunita requested:
When they reviewed the documents, they noticed that several answers in the proposal form had been marked by the agent, not by the policyholder.
The Insurance Regulatory and Development Authority of India (IRDAI) requires insurers to:
If a policyholder disputes the rejection, the insurer must review the grievance through its internal grievance cell before the matter can be escalated further.
Sunita filed a written grievance with the insurer’s grievance officer. She attached:
A statement explaining that the form had been completed by the agent
Previous medical records showing no major hospitalization before the policy date
She also mentioned that if the grievance was not resolved, she would approach the Insurance Ombudsman.
More than ₹2.8 lakh was finally paid directly to the hospital.
1
Never rely on verbal statements. Ask for the written reason.
2
Check what information was actually recorded.
3
Gather prescriptions, test reports, and past treatment records.
4
Email or submit a written complaint to the insurer’s grievance officer.
5
Approach the Insurance Ombudsman or the consumer dispute mechanism if the insurer refuses relief.
The agent fills the proposal form without explaining questions.
You are asked to sign blank or partially filled forms.
Medical history is not read back to you.
You do not receive a copy of the completed proposal form.
Many families accept the rejection immediately and arrange funds through loans or savings.
Consumer experts say that a significant number of disputed health insurance claims are modified or partially approved after a proper grievance review.
“A health insurance rejection should be treated as the beginning of a review process, not the end of the claim. Consumers should demand documents, verify the proposal form, and use the grievance mechanism before accepting a denial.”
If your health insurance claim is rejected for a “pre-existing disease”:
Ask for the written reason.
Check the proposal form.
Gather medical records.
File a formal grievance.
Escalate to the Insurance Ombudsman if needed.
A well-documented challenge can often change the outcome of a rejected claim.