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Health Claim Denied for Pre-existing Disease: Appeal Steps
Direct answer: Ask the insurer for a written repudiation that names the exact policy clause and explains how the medical records support it. Compare the alleged condition, proposal-form disclosure, waiting period and treatment actually claimed. Send a document-indexed review to the insurer's grievance officer. If unresolved or unsatisfactory, escalate through IRDAI's Bima Bharosa portal and consider the Insurance Ombudsman. A cashless denial is not always a final rejection of reimbursement.
Last reviewed: 13 August 2026.
Separate four different disputes
“Pre-existing disease” is often used loosely. Your case may actually concern a waiting period, an exclusion, alleged non-disclosure, or a medical-necessity dispute. Obtain the final repudiation letter and highlight the clause cited. IRDAI's guidance requires a denial or repudiation communication to state reasons and refer to the corresponding policy conditions.
Do not accept a TPA's telephone statement as the final reason. The insurer, not merely the hospital desk, must communicate repudiation.
Build the appeal file
Arrange one PDF or indexed folder containing:
- policy schedule, customer information sheet and full wording;
- proposal form and declarations made at purchase;
- renewal history and portability/migration records;
- claim form, discharge summary, diagnostic reports and prescriptions;
- cashless correspondence and final repudiation letter;
- treating doctor's note addressing onset, diagnosis and connection to treatment;
- a page matching each insurer allegation with contrary evidence.
Never alter medical history. If a condition was disclosed, show where. If it was not known at proposal, produce contemporaneous records rather than merely asserting it.
Use the grievance ladder in order
- Request internal review by the insurer's grievance redressal officer.
- Ask for the clause-by-clause medical and contractual basis of the decision.
- If there is no satisfactory resolution within the prescribed grievance period, register and track the complaint on Bima Bharosa.
- Consider the Insurance Ombudsman where the complaint falls within its rules and limits.
- Preserve limitation dates for consumer or court remedies; do not let a portal complaint make you miss them.
IRDAI's current Bima Bharosa FAQ says the insurer should resolve a written complaint within 15 days, after which an unresolved or unsatisfactory grievance can be escalated to IRDAI.
What to ask the insurer to do
State a measurable remedy: withdraw the repudiation, reassess specified bills, pay the admissible amount with applicable interest, and correct any inaccurate claim-history entry. If only part of the bill is excluded, ask for the undisputed portion to be settled rather than treating the whole claim as all-or-nothing.
Frequently asked questions
Is cashless refusal the same as final claim repudiation?
Not necessarily. A policyholder may still use the reimbursement process, subject to the policy. Ask whether the communication is only a pre-authorisation decision or a final repudiation.
Should I quote a universal pre-existing-disease waiting period?
No. Use the current policy wording, issue date, continuity credits and applicable IRDAI framework. Do not assume every policy has the same period.
Can RTI order a private insurer to pay?
No. Use the insurer, Bima Bharosa, Ombudsman and legal remedies. RTI may be relevant only for records held by a public authority and does not replace the claim appeal.