Case Study: Rebuilding a ₹4.2L Mediclaim From a 'Final Rejection'

Names and identifiers are changed for privacy.

The case

A 52-year-old policyholder from Ahmedabad was admitted for a cardiac procedure. The insurer rejected the ₹4,17,500 claim citing pre-existing disease and "material non-disclosure".

What we found

• The condition (hypertension) was first diagnosed *after* the policy was issued. The treating doctor's letter confirmed this.
• The insurer's rejection letter quoted clauses that did not match the actual policy wording.
• The "non-disclosure" was a routine fitness certificate from an annual employer check-up — not a diagnostic record.

What we did

1. Pulled three years of medical records and the doctor's clarification letter.
2. Compared the rejection letter line-by-line with the policy wording — found two material misquotes.
3. Drafted a structured representation citing the IRDAI Master Circular 2024 and two Ombudsman orders.
4. Filed with the insurer's Internal Ombudsman.

Outcome

Full settlement of ₹4,17,500 within 6 weeks of representation. No legal proceedings required.

This is the most common kind of case we see — the policyholder had a fair claim and a fair policy. Only the paperwork was missing.