You pay premiums year after year expecting peace of mind — but when it’s time to file a health insurance claim, it gets rejected. Why?
More often than not, the reason lies buried in your policy’s “disclosure” or “pre-existing condition” clause — the one small detail that many people skip reading but that can completely derail your claim.
Let’s uncover what this clause means, why it’s so critical, and how to protect yourself from claim surprises.
The Clause That Causes Trouble: Non-Disclosure of Pre-Existing Conditions
One of the most common reasons for health insurance claim rejection is “non-disclosure” — not revealing your complete medical history when you buy the policy.
Even if it’s unintentional, missing details like:
past surgeries,
lifestyle diseases (like diabetes or hypertension), or
minor ongoing treatments
can give the insurer grounds to deny your claim later.
Insurance companies rely on your medical disclosures to calculate risk and premium. Any mismatch between what’s declared and what’s discovered during hospitalization can trigger a “breach of contract” — making your policy invalid for that claim.
How This Clause Affects Your Claim
When you buy a health policy, insurers usually include a waiting period (typically 2–4 years) for pre-existing diseases.
If you disclose everything upfront, your coverage activates normally after this period.
But if you hide or forget to mention something, the insurer can:
Reject your claim,
Cancel your policy, or
Deny renewal — especially if the issue surfaces during treatment.
This clause also extends to non-disclosure of habits like smoking, alcohol use, or even regular medication — factors that affect your medical risk profile.
How to Protect Yourself
✅ 1. Always Disclose Truthfully
Be transparent about your full medical history, even if it increases your premium. It’s far better to pay a bit more than lose coverage during an emergency.
✅ 2. Keep All Medical Records Updated
Store your reports and prescriptions safely. During claim processing, insurers may ask for old medical documents for verification.
✅ 3. Review Policy Terms Regularly
Health insurance isn’t a one-time purchase. Revisit your policy every year to update details — especially after new diagnoses, surgeries, or medications.
✅ 4. Understand Waiting Periods
Know which conditions are covered immediately and which have waiting periods. This helps you plan treatments and expenses better.
✅ 5. Buy from Trusted Insurers
Choose IRDAI-registered insurers with transparent policies and a strong claim settlement ratio.
Real-World Example
Imagine Riya, a 35-year-old professional, buys a ₹10 lakh health insurance policy. She forgets to mention that she was once treated for thyroid imbalance.
Three years later, she files a claim after hospitalization for related complications — only to have it rejected under the “non-disclosure clause.”
This small omission cost her over ₹2.5 lakh out-of-pocket.
Pro Tip
If you’re unsure what counts as a “pre-existing condition,” disclose everything. It’s the insurer’s job to decide what’s relevant — not yours to guess.
Conclusion
A single overlooked clause — non-disclosure or pre-existing condition — can make or break your health insurance claim.
The takeaway is simple:
Transparency today prevents denial tomorrow.
When it comes to health insurance, honesty truly is the best policy.
❓ FAQs
1. What is a pre-existing condition in health insurance?
It refers to any illness, injury, or condition that existed before you bought the policy, even if it wasn’t treated recently.
2. Can an insurer reject my claim after years of paying premiums?
Yes, if it finds that key medical information was withheld at the time of policy purchase.
3. How can I avoid claim rejection?
Always disclose complete health details, even minor conditions, and keep your policy information up to date.
4. Is there a cooling-off period for claim rejections?
You can approach the Insurance Ombudsman or file a complaint with IRDAI if your claim was unfairly rejected.
5. Do group health policies also have this clause?
Yes, though group policies (like employer insurance) often have fewer disclosure requirements. However, it’s still best to be transparent.
Published on : 27th October
Published by : SMITA
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