Health insurance claim rejected? How to challenge it

What the law says

Who has to prove what on a pre-existing disease. This is the heart of most rejections, and the law places the burden on the insurer. When an insurer repudiates a claim on the ground that you did not disclose a pre-existing disease, it must prove, with tangible medical evidence of prior diagnosis or treatment, that the disease existed, that it was material, and that you actually knew of it and deliberately suppressed it. A panel doctor's speculation that a condition "must have" pre-existed, or an uncorroborated investigator's report, is not enough.

Your duty is bounded by what you knew. Insurance runs on utmost good faith, so you must honestly disclose the material facts within your actual knowledge, and concealing a serious illness you knew about can validly defeat a claim. But the duty extends only to what you knew or could reasonably be expected to know. You cannot be penalised for a latent condition you had no knowledge of, and an undisclosed symptom that was never diagnosed or treated as a disease is not, by itself, a valid ground to reject.

Two things that weaken a rejection. First, if the insurer had you medically examined before issuing the policy and was satisfied with your health, it generally cannot later repudiate on a pre-existing disease it failed to detect. Second, if a material health question was left blank in the proposal form, the insurer had to verify it before issuing the policy, and cannot later claim you actively suppressed it.

Common conditions and the need for a link. General diabetes or hypertension does not automatically count as a pre-existing "disease" for an unrelated cardiac event unless the insurer shows its severity and a direct clinical connection. And a repudiation is improper where the condition said to be undisclosed has no connection with the actual cause of hospitalisation or death.

Renewal and a disease that developed later. An insurer cannot refuse to renew, or quietly change or cap the cover, without informing you; failing to tell you of a material change at renewal is a deficiency in service. A public-sector insurer cannot exclude a disease simply because it developed after the cover first began.

Where to take it, including a free route. You have more than one forum.

• The Insurance Ombudsman is a free, pre-litigation forum. It hears complaints of partial or total repudiation, delay in settlement, and non-observance of the IRDAI's policyholder-protection regulations, and decides in a fair, cost-efficient, and non-technical way. Courts respect a fair ombudsman award and will not lightly disturb it.
• A consumer commission can hear you too: a policyholder, and a beneficiary of the policy, is a "consumer", so you can file for deficiency in service and seek the claim with compensation.
• A Permanent Lok Adalat can settle insurance claims up to one crore rupees.
• Where the insurer alleges fraud and the facts are seriously disputed, needing detailed evidence, a civil suit, not a writ petition, is the proper forum.

What you can do

1. Get the written repudiation letter and read the exact ground it states. The insurer is generally confined to the ground it actually gave, so that ground defines what you have to answer.
2. Gather your documents: the policy and the proposal form, your full medical records, the hospital bills, the correspondence with the insurer or TPA, and any pre-policy medical test the insurer itself conducted.
3. If the ground is a pre-existing disease, remember the insurer must prove you knew of it and deliberately suppressed it, with concrete medical evidence. Point to any pre-policy medical check the insurer did, or any material question it left unverified.
4. Escalate first to the insurer's grievance cell, and if it is not resolved, take it to the Insurance Ombudsman. This route is free and built to resolve these disputes without heavy litigation.
5. Alternatively, or next, file a complaint before the consumer commission for deficiency in service, seeking the claim amount with compensation. A beneficiary of the policy can also bring the claim.
6. For a claim up to one crore rupees, a Permanent Lok Adalat is another option. Where the insurer alleges fraud and the facts are heavily disputed, a civil suit is the proper route.

Cases that matter

Pnb Metlife India Insurance Company Limited v. Mandeep Devi, High Court of Punjab and Haryana (2025). The insurer repudiated a claim alleging an undisclosed pre-existing cancer but produced no medical evidence of prior treatment. The court affirmed that the entire burden of proving suppression rests on the insurer, which must produce concrete, tangible evidence and cannot rely on guesswork or uncorroborated investigator reports.

Bajaj Allianz Life Insurance Company Ltd. v. Punamlata, High Court of Allahabad (2024). The insurer had conducted its own medical examination before issuing the policy and was satisfied, then later tried to repudiate on a pre-existing ailment. The court held that once an insurer independently satisfies itself of the proposer's health before issuing the policy, it cannot afterwards escape liability on the basis of a pre-existing disease.

National Insurance Company Ltd. v. Sanjib Kumar Das, High Court of Orissa (2019). The claim was rejected on the footing that diabetes and hypertension were undisclosed pre-existing diseases behind a cardiac event. The court held that general diabetes or hypertension does not automatically qualify as a pre-existing disease for an unrelated heart ailment unless the insurer shows its specific severity and a direct clinical contribution.

United India Insurance Company Ltd. v. Manubhai Dharmasinhabhai Gajera, Supreme Court of India (2008). The Court held that public-sector insurers must act fairly and reasonably, that they cannot refuse renewal simply because claims were made earlier or a new disease developed after the cover began, and that an exclusion clause must be given strict effect on its actual terms. It is the anchor on fair renewal and newly developed illnesses.