Health claim rejected for a waiting period

A health policy can carry three kinds of wait. The initial waiting period from the start of cover is set by your policy and shown in its Customer Information Sheet; IRDAI's current rules leave the number to the insurer. A specific waiting period for named illnesses or procedures can run up to 36 months and does not apply to an accident. A waiting period for a disclosed pre-existing disease can also run up to 36 months of continuous cover (IRDAI (Insurance Products) Regulations 2024, Schedule III).

Time already served carries over. When you port to another insurer, or migrate to another policy with the same insurer, the credit you built up against the specific and pre-existing waiting periods moves with you, along with the sum insured and the no claim bonus (Health Master Circular, paras 11 and 12). A renewal paid within the grace period keeps the credit. A renewal paid after it is a break in the policy.

So check when your first policy began, whether every renewal fell inside its grace period, and when the condition was first treated. If the insurer counted from the start of a ported or migrated policy rather than your first one, the rejection is open to challenge. The letter has to cite the policy term it relies on (para 17).

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.