Imagine paying health insurance premiums for years, only to have your claim rejected because of a surgery you had 15 years ago — one that has had no effect on your current health. Unfortunately, this isn’t an uncommon situation in India’s insurance landscape.
The question is — is such a rejection justified, or is it an unfair denial of benefits? Let’s break down what the rules say and how you can protect yourself.
The Case: What Happened
In a recent case, a policyholder’s health insurance claim was denied because the insurer discovered a 15-year-old surgical history that wasn’t declared in the original policy proposal. The company cited non-disclosure of medical history as the reason for rejection.
The policyholder, however, argued that the surgery was minor, unrelated to the current illness, and took place long before the policy purchase.
This raises an important question: how far back can insurers look — and what counts as “non-disclosure”?
Understanding Non-Disclosure and Its Limits
Insurance contracts are based on the principle of “utmost good faith”, meaning both parties must disclose all material facts. However, the Insurance Regulatory and Development Authority of India (IRDAI) provides clear guidance:
🔹 After 8 years, policies become “incontestable.”
Once a health insurance policy has been active for 8 continuous years, insurers cannot reject claims citing non-disclosure or misrepresentation (except in cases of proven fraud).
So, if your policy is older than 8 years and you’ve been honest in disclosures, your claim should not be rejected for a surgery that happened 15 years ago.
When Rejection Might Be Justified
A rejection may be considered justified if:
The surgery was related to the current illness or claim.
There was deliberate concealment of a major health issue.
The policy was new, and the undisclosed condition was material to underwriting.
Example: If a person failed to disclose a heart surgery and later files a claim for a cardiac condition, the insurer could reasonably deny it.
When It’s Likely Unfair
Claim rejection may be unjustified if:
The surgery was minor or unrelated (e.g., appendix removal 15 years ago).
The insurer cannot prove intentional non-disclosure.
The policy has been active for more than 8 years (protected by IRDAI’s moratorium rule).
In such cases, the policyholder can challenge the decision through:
The insurer’s grievance redressal cell
The Insurance Ombudsman
IRDAI’s consumer grievance portal (IGMS)
What Policyholders Should Do
✅ Disclose all past medical history — even if it feels irrelevant.
✅ Keep medical records handy for verification.
✅ Read the policy terms carefully to understand exclusions.
✅ Renew policies consistently to enjoy contestability protection.
✅ Challenge wrongful denials through official channels.
Expert View
Industry experts say insurers often use “non-disclosure” as a convenient ground for rejection — especially for older policyholders. However, under current IRDAI norms, transparency and consumer protection are key priorities.
💬 “A surgery from 15 years ago, unrelated to the current illness, cannot be considered a valid ground for claim rejection under an active, long-term policy,” notes a financial advisor.
Conclusion
While insurers have the right to investigate claims, they also have a duty to act fairly. Rejections based on long-past surgeries — especially unrelated or minor ones — often lack legal standing.
Policyholders must be vigilant, transparent, and persistent in defending their rights. Remember, knowing the rules is the first step to protecting your claim.
FAQs
Q1. Can an insurance company deny a claim for an old surgery?
Not if the surgery is unrelated and the policy has been active for over 8 years, as per IRDAI’s guidelines.
Q2. What is the IRDAI’s 8-year rule?
It states that after 8 continuous years of coverage, an insurer cannot deny claims for non-disclosure unless there’s proven fraud.
Q3. What can I do if my claim is unfairly denied?
You can appeal to the Insurance Ombudsman or file a complaint through the IRDAI Grievance Redressal (IGMS) platform.
Q4. Should I disclose surgeries that happened over 10 years ago?
Yes, always disclose past medical history to avoid future disputes.
Q5. Can I switch insurers after a claim rejection?
Yes, you can port your health insurance policy with all accumulated benefits to another insurer.
Published on : 2nd November
Published by : SMITA
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