Health Claim Rejected for Pre-Existing Disease? Here Is How to Appeal

Who this guide is for

This guide is for anyone in India whose health insurance claim has been rejected — fully or partially — on the ground that:

• the condition is a pre-existing disease and the waiting period has not expired;
• you did not disclose the condition at the time of buying the policy; or
• the insurer's medical investigator has found a condition in old records and labelled it undisclosed.

It is also relevant if you are unsure whether a condition you had years ago counts as a PED under current IRDAI rules. The guide covers both group health policies (employer-provided) and individual/family floater policies. It applies whether your insurer is a public sector company or a private one, though some sections — particularly the RTI angle — apply only to public sector insurers.

If your claim was rejected for a different reason — a procedural lapse, a non-medical deduction, or a cashless denial — see our related guide on health insurance claims denied for non-disclosure or the broader insurance claim rejection recovery guide.

What you can do this weekend

Friday evening

Pull out the rejection letter (or forward the email to yourself so it is easy to find). Read it carefully and note:

• the exact ground cited — is it "waiting period not over", "non-disclosure of material fact", or a named exclusion clause?
• the clause number from your policy document they have relied on;
• the deadline, if any, for filing a representation (some insurers specify 15 or 30 days).

Then find your original policy document and your proposal form. Many insurers send both at inception by email or post. If you cannot find the proposal form, write to your insurer tonight requesting a copy — you are entitled to one. If your insurer is a PSU, note that you can compel production via an RTI application.

Saturday

Visit your treating doctor or the hospital where treatment was given. Ask for:

• a certified copy of the discharge summary (if hospitalisation was involved);
• copies of all prescriptions and diagnostic reports going back to the date the condition was first detected;
• a treating doctor's letter confirming the date of first diagnosis and the clinical course of the condition.

Now check the date of first diagnosis against your policy start date. Under IRDAI rules, a condition is a pre-existing disease only if it was diagnosed or treated within 36 months before the policy start date. If the first diagnosis is after your policy began, or if it is beyond that 36-month window, you have a strong case.

Also check how many continuous years you have held health insurance (counting any portable or migrated policies without break). If you have 60 months or more of unbroken cover, the moratorium period applies — the insurer cannot repudiate on non-disclosure grounds unless they can prove fraud.

Sunday

Draft your formal representation to the insurer's Grievance Redressal Officer (GRO). Use the complaint template in this guide as a starting point. Attach:

• a copy of the rejection letter;
• the relevant pages of your proposal form showing what you disclosed;
• the treating doctor's letter and diagnostic reports establishing the timeline;
• your policy document (first page and the relevant exclusions clause).

Send it by registered post or email with a read receipt. Keep the dispatch proof. You now have a paper trail. Also register on bimabharosa.irdai.gov.in so you are ready to escalate if the GRO does not resolve matters in 14 days.

Documents and evidence checklist

Step-by-step action plan

Step 1 — Understand "pre-existing disease" under current IRDAI rules

Under the current IRDAI framework, a pre-existing disease is defined as any condition, ailment, injury, or disease that was diagnosed or treated within 36 months before the policy start date. This is a critical threshold. If the first documented diagnosis occurred after your policy started — even if you had vague symptoms earlier — it does not automatically qualify as a PED.

There is an important distinction between non-disclosure and a genuinely undiagnosed condition. Non-disclosure means you knew about a diagnosis or treatment and did not mention it in the proposal form. A genuinely undiagnosed condition is one that was latent — no doctor had ever detected or treated it before your policy began. The IRDAI's current definition protects the latter category: if you had no diagnosis and no treatment within the relevant window, the insurer should not label it a PED.

Insurers sometimes use findings from a post-claim investigation — like a mention of a symptom in an old casualty note — to construct a narrative of prior knowledge. If this is happening in your case, the burden is on the insurer to prove that you had a diagnosis or treatment, not merely a symptom, within the relevant period.

Step 2 — Get your proposal form and compare disclosures

The proposal form is the document you signed when you applied for the policy. It lists the health questions you answered. If the insurer is saying you failed to disclose, your first job is to read exactly what you answered. Many disputes arise because:

• the question was ambiguous and you answered reasonably;
• you disclosed a related but not identical condition;
• an agent filled the form and did not record your oral answer correctly;
• the condition did not exist at the time you filled the form.

Insurers must send the proposal form copy when the policy is issued. If yours is missing, write to your insurer demanding it. If your insurer is a PSU and they delay, use an RTI application to the Central Public Information Officer of that company — the proposal form is a record relating to your claim and you are entitled to it under the RTI Act 2005. See the RTI section below for the exact request language.

Step 3 — Check the waiting period status

Read the waiting period clause in your policy carefully. Under IRDAI rules, the maximum waiting period an insurer can impose for pre-existing diseases is 36 months. Count the months from your policy start date (or from the date of portability from a prior insurer, which counts). If you are past 36 months, the insurer cannot use the waiting period as a reason for rejection. Ask your insurer for a written confirmation of whether the waiting period has expired.

Also check whether you have 60 or more months of continuous health insurance coverage (counting ported policies with no gap). If yes, you are in the moratorium zone. The insurer can only reject your claim if they can demonstrate fraud — not mere non-disclosure. This is a very high bar that shifts the burden entirely to the insurer.

Step 4 — File a formal representation with the insurer's GRO

Every insurer is required to have a Grievance Redressal Officer. Address a written representation to the GRO by name (check the insurer's website for the current GRO details). Your representation should:

• state the policy number, claim number, and date of rejection letter;
• quote the exact ground cited in the rejection letter;
• set out your counter-argument clearly (waiting period has expired / condition was disclosed / condition was not a PED at inception / moratorium applies);
• attach the documents from the checklist above;
• request a specific outcome — reversal of rejection and settlement of the claim.

The complaint template further below is a ready-to-use starting point. Send by registered post with acknowledgement due and also by email. The insurer must acknowledge your grievance promptly and resolve it within the IRDAI-prescribed timeframe.

Step 5 — Escalate to Bima Bharosa (IRDAI IGMS)

If the GRO does not respond to your satisfaction within 14 days, register a complaint on the Bima Bharosa portal (IRDAI's Integrated Grievance Management System). You will receive a complaint reference number. The portal routes your complaint to the insurer and monitors the response timeline. The IRDAI can take regulatory action against insurers who persistently ignore or improperly handle grievances.

Step 6 — File a complaint with the Insurance Ombudsman

If the insurer gives a final rejection or does not respond within 30 days of your grievance, you can approach the Insurance Ombudsman in whose jurisdiction your policy was issued or the insurer's branch is located. The Ombudsman service is free of charge. It covers health insurance disputes up to ₹50 lakh. The Ombudsman's award is binding on the insurer but not on you — if you are dissatisfied with the award, you can still go to the consumer forum.

Find the correct Ombudsman office and contact details on policyholder.gov.in. Our detailed guide on insurance ombudsman complaint format for health insurance walks you through the filing process.

Also read: how to file an insurance complaint with IRDAI and the step-by-step guide to filing an IRDAI complaint after a health claim rejection.

Step 7 — Consumer forum as a final escalation

If the Ombudsman's award does not cover your full loss, or you disagree with it, a consumer forum (District Consumer Disputes Redressal Commission) is available. You can file a complaint claiming deficiency of service. Consumer forums have issued many orders against insurers for wrongful PED-based rejections. Our guide on filing a consumer court complaint against a health insurance company covers the process in detail. Check current jurisdictional thresholds on the official consumer protection portal as these are set by rules.

Escalation ladder

Copy-paste complaint template

Replace the text in square brackets with your own details before sending.

When RTI can help

The Right to Information Act 2005 applies to public authorities. In the insurance context, the following are public authorities and are directly subject to RTI:

• New India Assurance Company Limited (government-owned)
• United India Insurance Company Limited
• National Insurance Company Limited
• Oriental Insurance Company Limited
• Life Insurance Corporation of India (LIC) for any health riders or Aarogya Rakshak policies
• Public sector hospitals (government hospitals, district hospitals, AIIMS, ESIC hospitals) where you were treated

If your insurer is one of the above, you can file an RTI application to the Central Public Information Officer (CPIO) of the company requesting:

• a certified copy of your signed proposal form;
• the insurer's internal claim investigation report;
• the GRO's file noting on your grievance;
• the criteria or guidelines used to classify your condition as a pre-existing disease;
• the name and qualifications of the medical officer who reviewed the claim.

RTI applications to PSU insurers must currently be filed by post (not email, as per their standing instructions). The fee is typically ₹10 payable by postal order or demand draft, though verify the current fee and payment method on the insurer's RTI portal. The CPIO must respond within 30 days. If they do not, or if information is withheld without justification, you can file a First Appeal within 30 days of the reply, and then a second appeal or complaint to the Central Information Commission (CIC). See our guides on how to file an RTI application and how to file a first appeal under Section 19. The RTI Playbook covers the full strategy for using RTI in disputes.

If the public hospital where you were treated denied or lost your old treatment records, file an RTI with that hospital's PIO to obtain certified copies. Those records may be critical to proving — or disproving — the timeline the insurer's investigator has constructed.

When RTI will not help

RTI does not apply to private insurers. Companies such as Star Health, Niva Bupa, HDFC Ergo, ICICI Lombard, Max Bupa, Aditya Birla Health, or Bajaj Allianz are private entities. The RTI Act explicitly applies only to public authorities funded by or under substantial government control. For private insurers:

• Use your policy terms and IRDAI's policyholder protection regulations to demand documents;
• File a grievance on Bima Bharosa (IRDAI IGMS), which applies to all insurers;
• Approach the Insurance Ombudsman, which covers all licensed health insurers;
• File at a consumer forum, which applies universally.

RTI also will not help you get IRDAI's internal deliberations on a specific complaint — IRDAI may decline to share third-party claim dispute details under the RTI Act's exemptions. The correct route for complaint redressal against any insurer is Bima Bharosa, the Ombudsman, and consumer forums.

Common mistakes to avoid

• Not getting the rejection in writing. Always ask for the rejection letter in writing. A verbal intimation or a TPA SMS is not sufficient to trigger the appeal clock or to build a case. Write to the insurer and TPA demanding the written rejection with the exact policy clause cited.
• Assuming the insurer's timeline of your medical history is correct. Insurers often send a medical investigator who collects old records. The investigator may misinterpret a symptom as a diagnosis, or cite an old hospital record inaccurately. Always cross-check their report against what your treating doctor says and what the original records actually show.
• Confusing non-disclosure with a genuinely undiagnosed condition. If you truly did not know about a condition when you applied, say so clearly — supported by a doctor's letter confirming no prior diagnosis or treatment. Do not accept the insurer's framing if the facts do not match.
• Missing the appeal window. Some policies specify a window of 15 to 30 days to file an internal representation. Check your rejection letter and policy terms immediately. Missing this window may not bar all remedies, but it weakens your case.
• Going straight to court without exhausting IRDAI routes. Consumer forums and courts will often ask whether you tried the Ombudsman first. The Ombudsman is free, faster, and binding on the insurer. Use it before incurring legal costs.
• Not keeping a record of every communication. Every email, registered post receipt, and portal reference number is evidence. Create a dedicated folder — physical or digital — and log every interaction with dates and outcomes.
• Letting your health policy lapse during the dispute. Continue paying premiums. A lapsed policy resets the waiting period and destroys the continuity credit you have built up. Your dispute is about a past claim — it does not justify letting the policy lapse.
• Not checking portability credit. If you ported your policy from another insurer, the waiting period credit and continuity toward the moratorium carry over. Many policyholders are unaware of this. Check portability details in your current policy or with your prior insurer.