Insurance claim rejected over a 15-year-old surgery; is it justified?

Q: My husband was hospitalized from 14th to 22nd July 2024 for the treatment of chronic liver disease (CLD) at a reputed hospital. After discharge, we submitted a reimbursement claim with all the required medical and policy documents.

However, the insurance company rejected the claim, stating that the insured had undergone varicose vein surgery nearly 15 years earlier, which they considered a pre-existing disease (PED).

The insurer concluded that the current ailment — chronic liver disease — was related to this past surgery. Is this claim rejection justified? What should the policyholder do next?

—Name withheld on request

Under IRDAI’s definition, a pre-existing disease is one diagnosed or treated within 48 months prior to the inception of the policy. A surgery performed 15 years ago, with no continuing symptoms or treatment, cannot be classified as a current pre-existing condition, especially when varicose veins and chronic liver disease are medically unrelated.

Demand full clarification

In this case, the insurer’s decision appears medically and logically unjustified. Request a detailed claim rejection letter from the insurer, asking not only for the specific policy clause and medical reasoning, but also for the proofs and medical correlation used to connect the past surgery with the current ailment. Then file a written grievance with the insurer’s internal grievance redressal team (response expected within 15 days).

If not satisfied, raise the complaint on IRDAI’s Bima Bharosa platform for formal regulatory review. If the issue remains unresolved, escalate the matter to the Insurance Ombudsman. As a final recourse, approach the consumer court for deficiency in service or unfair claim rejection.

Such cases highlight the need for insurers to interpret the pre-existing disease clause with medical evidence and fairness, not mechanical assumptions. Health insurance exists to protect families in times of crisis — not to penalize them for unrelated medical histories from decades past.

(Shilpa Arora is co-founder and COO at Insurance Samadhan)