Health Claim Rejected as Pre-existing? Here's What You Can Do

Health insurance rejections citing "pre-existing disease" (PED) are one of the most common — and one of the most frequently *wrongful* — claim denials in India.

Insurers often invoke the PED clause whenever the policyholder is diagnosed within the first two to four years of the policy. But the law and IRDAI guidelines are very clear: a condition is only a PED if it was *diagnosed* or *treated* before the policy was bought.

When a PED rejection is wrongful

• The illness was first detected only after the policy started.
• There is no medical record showing diagnosis or treatment before the policy.
• The insurer relies on a single suggestive line in a discharge summary without supporting evidence.
• The waiting period for the specific condition has expired.

How we build the appeal

1. **Re-read the policy wording.** PED definitions vary widely across insurers. Half the rejections fall apart at this step alone.
2. **Reconstruct the medical chronology.** We work with the treating doctors to issue clarifying letters — when did the symptoms begin, when was the diagnosis made.
3. **Pull the cumulative bonus & continuity history.** If the policy was ported, the waiting period rules change.
4. **Draft a structured representation** quoting the exact clauses, IRDAI master circulars and previous Ombudsman orders.

What is the likely outcome?

In our experience, **roughly 6 in 10 wrongful PED rejections** are reversed at the insurer level once a proper representation is made. The remaining are usually settled either at the Internal Ombudsman or the Insurance Ombudsman — both free routes for the policyholder.

A rejection letter is not the end of the road. Read the policy wording carefully and act within the time limits.