Health claim rejected for a pre-existing disease

Under IRDAI's rules a pre-existing disease is a condition a doctor diagnosed, or for which medical advice or treatment was recommended or received, in the 36 months before the policy started (IRDAI (Insurance Products) Regulations 2024, Schedule III). A condition you disclosed can carry a waiting period. That wait can be no longer than 36 months of continuous cover.

After 60 continuous months of cover, counting renewals, portability and migration, the insurer cannot contest the policy or a claim for non-disclosure or misrepresentation. Established fraud is the only ground left. If the sum insured was raised later, the 60 months run afresh on the increase alone.

Inside those 60 months the insurer can rely on non-disclosure, but the rejection still has a process to pass. It needs the approval of the insurer's Product Management Committee or a three-member sub-group, and the letter has to cite the specific policy term it relies on (IRDAI Master Circular on Health Insurance Business, para 17). Check the letter for both, then set the date of diagnosis against the date the policy began.

To challenge it, complain to the insurer in writing. It has 14 days to resolve the complaint. If it rejects it, gives an answer you are unhappy with or stays silent for a month, the Insurance Ombudsman takes the complaint free of charge within one year, for awards up to ₹50 lakh, when the policy is personal or held by a sole proprietor or micro enterprise. The checker works out those dates for your claim.