Imagine you or a family member were hospitalised recently for a serious ailment, made the claim, and provided all required documents — only to find the insurer rejecting it because of a surgery you had 15 years ago. The insurer argues this old surgery qualifies as a “pre-existing condition”, and therefore the current claim is invalid.
Is this kind of rejection fair and justified? Essentially: no — at least based on regulatory norms and reasonable interpretation. Let’s unpack why, and what you can do if you’re in this situation.
What is a “pre-existing condition” in health insurance?
In general health insurance practices, a pre-existing disease (PED) or condition is one that was diagnosed or treated before the policy was issued, or within a specified time horizon before policy inception. Insurers often impose a waiting period (for example 24-48 months) before the cover kicks in for such conditions.
If a surgery or ailment is very old, and has not required continuing treatment, and/or does not relate to the claim in question, then classifying it as a PED for the current ailment is questionable.
Why rejecting a claim on a 15-year-old surgery looks suspect
If the surgery happened 15 years ago, with no follow-up treatment, and no continuation of symptoms, it is weak to argue it directly contributes to the current illness.
Regulatory discussions indicate that a surgery distant in past, which did not recur or require ongoing treatment, should not automatically be treated as a pre-existing disease for current claim purposes.
If the insurer cannot show a medical link between the old surgery and the current ailment, then rejecting on that ground may be unreasonable.
Furthermore, insurance laws emphasise utmost good faith by both parties and prohibit unfair exclusions without justification.
When might the insurer have a valid reason?
While a 15-year-old surgery rejection often looks unfair, there are scenarios where the insurer may be justified:
If the surgery had complications or the condition has been ongoing, requiring treatment, follow-ups or medication — then it may still be relevant.
If the policy proposal form asked for past surgeries and you did not disclose the 15-year-old surgery, then non-disclosure might trigger rejection.
If the policy has an explicit clause that links the kind of surgery done, its recurrence, or related ailment as excluded — then claim rejection may align with policy terms.
What should you do if this happens to you?
Request detailed explanation from insurer — ask for the exact clause they are relying upon, the medical reason linking the old surgery to the current claim, and the documents they used.
Gather your documentation — get records of that surgery, follow-up treatments (or lack thereof), your current ailment’s diagnosis, and any medical opinion showing no connection to the old surgery.
Check your proposal/underwriting declaration — whether you disclosed the old surgery, and how the insurer treated it at policy issuance.
File a grievance — with the insurer’s internal grievance cell. If unsatisfied, escalate to the Insurance Ombudsman or consumer forum.
Seek medical opinion — a doctor’s note that clarifies your current ailment is not connected to the old surgery can be powerful.
Final thoughts
An insurance claim denial based purely on a surgery from 15 years ago without medical linkage to the current illness is generally not justified. Insurance is meant to provide protection, not penalise for remote history that has not recurred.
That said, every case depends on policy wording, disclosure history, medical evidence and the underwriting process. If you find yourself in such a situation — review your policy carefully, organise your medical evidence, and be ready to challenge the rejection assertively.
FAQs
Q1. Can an insurer always reject a claim because of old surgery?
No. They must show the surgery qualifies as a relevant pre-existing condition, was disclosed, and is linked medically to the current claim. A remote, non-recurring surgery may not by itself justify rejection.
Q2. What is a “waiting period” in health insurance?
The waiting period is the time after policy issuance during which certain conditions (including pre-existing diseases) or specific treatments are not covered.
Q3. Do I need to disclose every surgery I ever had?
You must truthfully disclose what the proposal form asks for, typically significant surgeries, diseases or treatments before policy, as required. Non-disclosure can lead to claim repudiation.
Q4. What if the insurer refuses to provide reasons for rejection?
You can request a formal repudiation letter with reasons. If not given, you can escalate to the grievance mechanism or ombudsman.
Q5. Is it worth pursuing the claim legally?
Yes — if the rejection seems arbitrary or unfair. Many consumer forums have ruled in favour of policyholders where insurers have been unreasonable.
Published on : 7th November
Published by : SMITA
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