Pre-Existing Disease Claim Rejection: How to Reply to Insurance Company

Part of the Health Insurance Claim Recovery Series by RightToInformation.Wiki.

If your health insurer has rejected your claim citing pre-existing disease non-disclosure, do not accept it on phone. Ask in writing for the exact policy clause, the medical record relied on and the proof of your prior knowledge, then reply with a structured letter quoting Section 45 of the Insurance Act 1938 and the IRDAI Master Circular dated 29 May 2024 moratorium provision.

This is a focused reply playbook. For the full statute analysis, see the deep PED article on Section 45 and the 8 year moratorium.

* PED stands for pre-existing disease. As per the IRDAI Master Circular on Health Insurance Business dated 29 May 2024, it means a condition diagnosed or treated by a physician within 36 months before the policy commenced. * Insurers often cite PED as an easy ground to deny claims even when the link between the current illness and any past record is weak or speculative. * The IRDAI 2024 circular cut the look back from 48 months to 36 months and added an 8 year moratorium. After 8 continuous renewals, the insurer cannot contest a claim on PED grounds except in a case of proven fraud. * Section 45 of the Insurance Act 1938 also bars the insurer from questioning the policy after 2 years from issue, except where the insurer proves deliberate fraud or material misrepresentation. * The burden of proof is on the insurer. You do not have to prove your innocence. The insurer must prove your guilt. * For deep statute analysis, see the full PED and statute article. This article is your reply playbook.

The insurer cannot just say “you had a PED”. To deny a claim on PED grounds, the insurer must establish all four elements together.

- Diagnosis by a physician within 36 months before the policy start. A self report or family history does not count. - Knowledge of the diagnosis on the part of the proposer at the time of the proposal. If you were never told, you cannot be said to have hidden it. - Materiality to underwriting. The undisclosed fact must have been so important that the insurer would have refused the policy or charged a higher premium. - Deliberate suppression, not an innocent or inadvertent omission. A genuine mistake or a confusing question does not amount to fraud.

If even one element is missing, the rejection cannot stand. Ask for proof of each element in writing.

- Get the rejection letter in writing on email or letterhead. Do not accept a phone call or a verbal denial. - Demand the exact policy clause, the medical record relied on, and the proof of your prior knowledge, all in writing. - Count completed renewals. If 8 or more, the IRDAI moratorium kicks in and blocks the PED defence. - Count days from the policy commencement. If 2 or more years, Section 45 of the Insurance Act 1938 shifts the burden of proof onto the insurer. - Pull the proposal form, premium receipts, medical records and discharge summary into one folder. - Email the grievance officer with the structured reply template below. - If no reasoned reply arrives in 15 working days, escalate to IRDAI Bima Bharosa.

Send these specific demands to the grievance officer. Do not paraphrase. Use exact wording.

* “Send the exact policy clause cited for the pre-existing disease rejection.” * “Send the medical record the insurer is relying on, with the date of physician diagnosis and the name of the treating doctor.” * “Send the proof that the policyholder had knowledge of the condition at the proposal stage.” * “Confirm whether the IRDAI Master Circular dated 29 May 2024 moratorium provision applies to this policy, given the number of completed renewals.” * “Confirm whether the Section 45 Insurance Act 1938 two year contestability period has expired.” * “Send the underwriting note from the proposal stage, including any pre policy medical check up results.” * “Confirm in writing whether the proposal form question relied on was clear, specific and free of medical jargon.”

Copy and paste this template into your email client. Fill in the bracketed fields. Send it from the registered email address on the policy.

Subject: Reply to PED rejection. Claim ID [CLAIM ID]. Policy [POLICY NUMBER]

To: [Insurer Grievance Officer email]
Cc: [TPA email]

Dear Sir or Madam,

I refer to the rejection of my health insurance claim dated [DATE OF REJECTION LETTER] citing pre existing disease non disclosure. I deny the rejection and request the following within 15 working days.

1. The exact policy clause cited for the rejection.
2. The medical record the insurer is relying on, with the date of physician diagnosis.
3. Proof that the condition was within my knowledge at the proposal stage.
4. Confirmation whether the IRDAI Master Circular dated 29 May 2024 moratorium provision applies to my policy, given [N] completed renewals.
5. Confirmation whether the Section 45 Insurance Act 1938 contestability period has expired, given the policy was issued on [DATE].
6. The underwriting note from the proposal stage.
7. A copy of the specific question in the proposal form the insurer says I failed to disclose.

I rely on the following authorities.

a. IRDAI Master Circular on Health Insurance Business dated 29 May 2024, paragraph on moratorium, which bars contestation of a claim after 8 continuous renewals on grounds of non disclosure or misrepresentation except in proved fraud.
b. Section 45 of the Insurance Act 1938 which shifts the burden of proving deliberate suppression of a material fact onto the insurer after 2 years from policy issue.
c. Supreme Court in Branch Manager, Bajaj Allianz Life Insurance v Dalbir Kaur 2020 and earlier authorities holding that the material fact must be in the policyholder's actual knowledge.
d. Supreme Court in Sulbha Prakash Motegaonkar v LIC of India 2015 holding that an inadvertent omission of an immaterial fact is not material non disclosure.

If a reasoned reply does not arrive within 15 working days, I shall file at IRDAI Bima Bharosa and pursue the Insurance Ombudsman remedy under the Insurance Ombudsman Rules 2017.

Regards,
[Your Name]
Policy: [POLICY NUMBER]
Claim ID: [CLAIM ID]
[Phone] [Email]

Save a PDF copy. Take a screenshot of the sent box. Note the sent date. The 15 working day clock starts on the next working day after receipt.

These are the most common excuses insurers use and the citizen friendly counter for each.

- “Patient told the hospital admission form they had diabetes for 5 years.” Hospital admission forms are not contemporaneous medical evidence. They are filled at a stressful moment, often by a relative, often by guesswork. Demand the original physician diagnosis record with date. - “Routine 2022 BP reading of 140 by 95 mmHg.” A single elevated reading is not a diagnosis of hypertension. Indian Council of Medical Research guidelines require sustained readings over time. One reading is not a PED. - “Family history of heart disease.” Family history is not a personal PED. It is a risk factor, not a diagnosis. The IRDAI definition is restricted to the proposer's own diagnosis or treatment. - “The disease appeared inside the 2 year waiting period, so it must have existed earlier.” First manifestation after the policy starts is not a PED unless the insurer proves a pre policy diagnosis. The wait period is a contractual exclusion, not a presumption of guilt. - “Online record search shows you had this condition.” Internet searches do not establish contemporaneous policyholder knowledge. Demand the source record with date and physician name. - “Your proposal form did not list this condition.” If the question was ambiguous, vague or used medical jargon, the rule of contra proferentem applies. Ambiguity is read in favour of the policyholder. Several High Courts and the National Consumer Commission have applied this rule. - “TPA gave a cashless denial at admission.” TPA denial at admission is not a final repudiation. You can still file for reimbursement on discharge. The TPA acts on partial records. The full assessment is the insurer's job. - “You lapsed and reinstated, so the moratorium has reset.” True that the moratorium counter restarts on reinstatement. But Section 45 protection still runs from the reinstatement date once 2 years pass. Do not let the insurer claim a permanent reset.

Escalate to IRDAI Bima Bharosa when any of the following is true.

* No written reply within 15 working days of your structured email. * The reply does not produce the actual medical record. A vague “as per our underwriting” line is not a reply. * The reply does not address the 8 year moratorium or the Section 45 contestability period. * The reply cites generic “non disclosure” without specifying the question or the record. * The reply relies on a hospital admission form or a TPA note rather than a physician diagnosis with date.

Complaint route:

Insurer Grievance Officer (15 working days) then IRDAI Bima Bharosa (15 working days) then Insurance Ombudsman (30 day SLA, free, complaint value up to Rs 50 lakh, award binding on the insurer if accepted by the complainant) then consumer court via edaakhil or the consumer court route.

You can also use IRDAI IGMS in parallel and the policyholder.gov.in complaint channels page for cross referencing the route. The IRDAI grievance summary page is at IRDAI grievance redressal and the Ombudsman procedure is at cioins.co.in procedure. The IRDAI toll free numbers are 155255 and 1800 4254 732.

* Replying verbally instead of in writing. A phone call leaves no record. The Ombudsman needs paper trail. * Accepting the rejection letter without demanding the underlying medical record. * Forgetting to count completed renewals to invoke the 8 year moratorium. * Forgetting to count days from policy issue to invoke the Section 45 shield. * Citing only “fairness” in your reply instead of the IRDAI circular and Section 45. * Ignoring the ambiguity in the proposal form questions. If the question was unclear, say so in writing. * Filing a fresh complaint at Bima Bharosa without first obtaining a written reply (or proof of non reply) from the insurer. * Letting the 1 year Ombudsman limitation expire while you wait for a courtesy reply. * Signing any “full and final settlement” voucher under pressure. Once signed, your claim is closed. * Letting the policy lapse during the dispute. Pay the renewal premium under protest and note it in writing.

Get these two numbers right before drafting your reply. They decide which legal shield you raise.

1. Continuous renewal count for the 8 year moratorium. Start from the date of original policy commencement. Add one for each renewal where the premium was paid before the grace period closed. Lapse and reinstatement resets the counter. Portability across insurers does not reset it if the porting was done within the 30 day window prescribed by IRDAI.
2. Section 45 contestability clock. Start from the date of policy issue or the date of reinstatement after a lapse, whichever is later. Add 2 years. If today is past that date, the burden of proof on misrepresentation shifts entirely to the insurer. Fraud still needs to be proved, with the insurer holding the bag.

Write both numbers at the top of your reply email. Make the insurer answer them directly. If they cannot, the rejection collapses.

A satisfactory reply produces the medical record, names the proposal form question, and addresses both the moratorium and Section 45 head on. Anything less is stalling.

• Reply gives a generic “non disclosure” line. Send a second email pointing to your specific demands and the 15 working day deadline. Note that you will treat further silence as a denial of a reasoned response and file at Bima Bharosa.
• Reply attaches a hospital admission form as the only proof. Reply: “Admission forms are not contemporaneous medical evidence. Send the physician's first diagnosis record with date.”
• Reply cites a “general practitioner consult” 8 years ago for an unrelated cough. Reply: “A consult is not a diagnosis. Send the diagnosis record. Also confirm continuous renewals from that date to confirm the 8 year moratorium status.”
• Reply ignores the moratorium and Section 45. Reply: “Both are statutory shields, not optional. Confirm the position on each in writing within 7 working days.”
• Reply offers a “without prejudice” reduced settlement. Note in writing that you will consider it only after the moratorium and Section 45 positions are addressed. Do not sign a “full and final” voucher.

When you escalate to Bima Bharosa, upload the following in one combined PDF.

1. The rejection letter.
2. Your structured reply email and proof of sending.
3. The insurer's reply or proof of non reply after 15 working days.
4. Your policy schedule and continuous renewal proof (premium receipts).
5. Proposal form (signed copy).
6. Hospital records, ICP, discharge summary.
7. Treating doctor's certificate confirming first diagnosis date.
8. Your summary letter naming the moratorium and Section 45 positions.

In the Bima Bharosa complaint text box, write three short paragraphs. Paragraph one states the facts. Paragraph two states the legal grounds (IRDAI Master Circular 29 May 2024 moratorium and Section 45). Paragraph three states the relief sought (full claim amount plus interest).

This article is the reply playbook. For the full legal reasoning, including the text of Section 45, the IRDAI moratorium clause word by word, the leading Supreme Court and National Commission decisions, and the proposal form contra proferentem analysis, read Mediclaim Pre Existing Disease Rejection: Section 45 and IRDAI 8 Year Moratorium. Read both articles together. Send the deep article as an annexure to your reply if the insurer keeps stalling.

As per the IRDAI Master Circular dated 29 May 2024, a pre existing disease is any condition, ailment, injury or related condition for which signs or symptoms existed, or which was diagnosed, or for which medical advice or treatment was received from a physician, within 36 months prior to the date the policy was issued or its first reinstatement. The earlier 48 month window has been reduced to 36 months.

Yes. Section 45 of the Insurance Act 1938 says no policy can be called in question on the ground of misstatement or suppression of a material fact after 2 years from the date of policy issue, except where the insurer proves that the suppression was fraudulent and made with the policyholder's knowledge. The burden of proof is on the insurer.

After 8 years of continuous policy renewals (without a break), the insurer cannot contest a health insurance claim on grounds of non disclosure or misrepresentation. The only exception is proved fraud. This moratorium applies to all indemnity health insurance policies issued in India after the circular came into force.

No. Family history is a risk factor, not a personal PED. The IRDAI definition requires the condition to have been diagnosed in or treated on the proposer's own person. A father's diabetes is not your PED.

It is weak evidence. The admission form is filled at a stressful moment, often by a relative under instruction from the registration desk. The Insurance Ombudsman and consumer commissions have repeatedly held that an admission form line is not contemporaneous medical evidence. The insurer must produce the actual physician diagnosis with date.

If the agent filled the form and you simply signed, you can plead agent assisted proposal. Several rulings hold that the agent is the insurer's representative. If the agent failed to record what you told him, the omission is on the insurer, not you. Demand the original proposal form and the agent code.

Yes. If you ported your policy from one insurer to another, your continuous renewal years carry across for waiting period and moratorium purposes. Demand that the new insurer count the years from the original policy commencement, not from the porting date.

Not on Section 45 grounds, unless the insurer proves fraud. After 2 years, contestability ends except in proved fraud. After 8 continuous renewals, even the fraud exception is restricted to actual proven fraud under the IRDAI moratorium clause. Five years sits well past both thresholds.

No. An accident claim is a fresh event after the policy started. The PED defence is meant for chronic illness claims linked to a pre policy condition. Insurers sometimes try to extend the defence to accident claims. Push back in writing and cite the accident date and the absence of any prior link.

It is an omission made without intent to deceive. For example, you forgot a single visit to a doctor 4 years ago, or you did not know the medical term used in the proposal form. The Supreme Court in Sulbha Prakash Motegaonkar v LIC of India 2015 held that an inadvertent or immaterial omission is not material non disclosure. The insurer must prove deliberate intent.

* Pillar: Full rejection guide * Hub: Health Insurance Claim Help India * Deep statute reference: PED, Section 45 and 8 year moratorium * Non disclosure rejection: how to reply * Waiting period rejection: how to reply * Insurance Ombudsman complaint format * Health insurance claim delay beyond 30 days * TPA denied cashless: how to reply * IRDAI Bima Bharosa walkthrough

Part of the Health Insurance Claim Recovery Series by RightToInformation.Wiki.

Last reviewed by RTI Wiki editorial team on 2026-05-16.