Health Insurance Claim Denied for Pre-existing Disease? Fight Back

Insurance companies often reject claims by alleging you hid a disease (like BP or Diabetes) at the time of purchase. However, under IRDAI rules, after 8 continuous years of policy (Moratorium Period), a claim cannot be rejected for non-disclosure. Even before that, if the disease is not related to the current hospitalization, they cannot reject it. If rejected, first appeal to the company's GRO (Grievance Redressal Officer). If they don't respond in 15 days, file a case with the Insurance Ombudsman.

Insurers have a 'claims investigation' team whose job is to find any past medical record of the patient. Even a minor mention of 'occasional headache' in a 5-year-old doctor's note can be used to claim 'chronic migraine non-disclosure'. They rely on the fact that most customers will give up after one rejection letter.

• The 'Rejection Letter' stating the exact reason and clause
• Your original proposal form (check what you declared)
• Discharge summary and all past medical records
• The 'Waiting Period' clause in your policy document

1. Gather Documentation: Collect all necessary evidence as outlined above.
2. First Level Contact: Reach out to the customer care or nodal officer of the concerned entity in writing.
3. Escalation: If unresolved within the stipulated time, escalate to the sector regulator or ombudsman.
4. Legal Action: As a last resort, consider sending a legal notice or approaching the consumer forum.

Here is the escalation ladder for this specific issue:

• Insurance Company's Grievance Redressal Officer (GRO)
• IRDAI Bima Bharosa Portal
• Insurance Ombudsman (for claims up to ₹30 Lakhs)

You can use the following template to draft your complaint email or letter:

To,
The Grievance Redressal Officer / Nodal Officer,
[Name of Company / Bank / Authority]

Subject: Complaint regarding health insurance claim denied pre-existing disease - [Your ID/Account/Booking Number]

Dear Sir/Madam,

I am writing to formally lodge a complaint regarding the issue of health insurance claim denied pre-existing disease.
On [Date], I experienced the following issue: [Briefly describe the problem].
Despite my initial requests, the issue remains unresolved.

I kindly request you to look into this matter urgently and provide a resolution within [Time Frame, e.g., 15 days].
Attached are the necessary documents supporting my claim.

Thank you,
[Your Name]
[Your Contact Information]

Do not sign 'settlement' papers for a lower amount if you are entitled to the full claim. Do not hide your medical history when buying a policy to save a few hundred rupees. Do not wait more than 1 year after rejection to approach the Ombudsman.

RTI can be filed with the IRDAI (Insurance Regulatory and Development Authority of India) to ask for the 'Claim Settlement Ratio' of a specific company for 'Pre-existing Disease' rejections, or to ask for the status of a specific complaint filed on the Bima Bharosa portal.

Q: How long does the resolution process usually take?
A: It depends on the escalation level, but typically initial grievances take 15-30 days, while Ombudsman or regulatory complaints may take 30-90 days.

Q: Do I need a lawyer to file a complaint?
A: In most cases involving consumer forums or ombudsmen, you do not need a lawyer and can represent yourself.

Q: Is there a fee to file a complaint with the Ombudsman?
A: No, filing a complaint with authorities like the RBI Ombudsman or Insurance Ombudsman is completely free of cost.

Q: What if the company ignores my legal notice?
A: If a legal notice is ignored, your next step is to file a formal case in the appropriate Consumer Disputes Redressal Commission or Civil Court.

Take immediate action by gathering your evidence and following the escalation ladder. Do not let companies take advantage of your silence. Use the official grievance channels to demand your rights.