Can my insurer deny claim for not disclosing an illness that was fully resolved before taking the policy?

My insurer rejected my reimbursement claim for acute motor axonal polyneuropathy (AMAN), saying I failed to disclose an old diagnosis of ankylosing spondylitis from 2008. That illness had been completely resolved and my doctor had certified full recovery, so I didn’t consider it relevant at the time of buying the policy. Can the insurer deny my claim on this ground, and what do current IRDAI (Insurance Regulatory and Development Authority) rules say?

A health insurance claim cannot be rejected merely because the policyholder had an illness many years ago, especially when that condition was fully treated, certified as resolved by the doctor, and has no medical connection with the present ailment. Irdai regulations require insurers to act on evidence and clear linkage, not assumptions.

In your case, ankylosing spondylitis was diagnosed in 2008, treated, and your doctor had certified complete recovery. At the time of buying the policy, you reasonably did not consider it relevant because it was no longer an active health issue. This is an important point: the duty of disclosure applies to material facts that are current, ongoing, or likely to affect risk at the time of proposal. A remote, fully-resolved condition often does not qualify as “material,” particularly when supported by a medical certificate.

For an insurer to invoke non-disclosure, two tests must generally be satisfied. First, the condition must have been present or active at the time of proposal. Second, there must be a direct or indirect causal link between that condition and the ailment for which the claim is made.

Here, ankylosing spondylitis (a rheumatological disorder) and acute motor axonal polyneuropathy (AMAN, a neurological condition) are medically distinct. Unless the insurer can produce medical evidence showing that the old condition contributed to, aggravated, or triggered AMAN, rejection on this ground is weak.

Moratorium protection, grievance options

Beyond that, the five-year moratorium period offers even stronger protection. After five continuous years of renewal, the insurer cannot question past medical history, non-disclosure, or misrepresentation, again except in cases where fraud is clearly established. All exclusions or conditions related to past illnesses effectively fall away after this moratorium, and claims must be settled in line with the policy terms.

Another important aspect is process fairness. Before rejecting a claim, insurers are expected to seek clarifications, call for additional documents, or allow the policyholder to submit medical opinions, including certificates from treating doctors. If a claim is repudiated without giving such an opportunity, it goes against the spirit of Irdai’s guidelines on fair claims handling.

Putting it all together: you had a long-resolved condition from 2008, medically certified as cured; your present ailment (AMAN) is unrelated; and if your policy had crossed the five-year moratorium, the insurer should not have relied on that old episode to deny the claim. You can take the grievance course of action, where you can write to the grievance redressal officer (GRO) of the company. If there is no response, then you can escalate the matter to Bima Bharosa or Insurance Ombudsman, where you get a chance to present your case fairly and demand justice.

Shilpa Arora, co-founder & COO, Insurance Samadhan

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