An insurance company has rejected a policyholder's reimbursement claim for acute motor axonal polyneuropathy (AMAN) treatment, citing failure to disclose a 2008 diagnosis of ankylosing spondylitis. The policyholder maintains that the old condition had been completely resolved with medical certification of full recovery, making it irrelevant at the time of purchasing the insurance policy.
Understanding the Insurance Claim Rejection
The case highlights a common concern among health insurance customers regarding disclosure requirements for past medical conditions. The insurer denied coverage for AMAN treatment, arguing that the policyholder should have revealed the 2008 ankylosing spondylitis diagnosis during the proposal stage.
However, the policyholder had valid reasons for not disclosing this information. The ankylosing spondylitis had been fully treated and certified as resolved by their doctor, making it no longer an active health concern when purchasing the insurance policy.
What IRDAI Regulations Say About Claim Denials
According to Insurance Regulatory and Development Authority of India guidelines, health insurance claims cannot be rejected merely because a policyholder had an illness many years earlier. The regulations specifically require insurers to act on evidence and clear medical linkage rather than assumptions.
Two critical tests must be satisfied for insurers to invoke non-disclosure. First, the undisclosed condition must have been present or active when the policy was purchased. Second, there must be a direct or indirect causal connection between that condition and the current ailment for which the claim is made.
In this specific case, medical experts confirm that ankylosing spondylitis (a rheumatological disorder) and acute motor axonal polyneuropathy (a neurological condition) are medically distinct conditions. Unless the insurer can provide medical evidence showing the old condition contributed to or aggravated AMAN, the rejection appears medically unsound.
The Five-Year Moratorium Protection
IRDAI regulations provide additional protection through the five-year moratorium period. After five continuous years of policy renewal, insurers cannot question past medical history, non-disclosure, or misrepresentation except in proven cases of fraud.
This moratorium effectively removes all exclusions or conditions related to past illnesses, requiring claims to be settled according to policy terms. If the policyholder had maintained continuous coverage for over five years, the insurer's reliance on the 2008 medical episode becomes even more questionable.
The regulatory framework also emphasizes process fairness. Before rejecting any claim, insurers must seek clarifications, request additional documents, and allow policyholders to submit medical opinions from treating doctors. Claim repudiation without providing such opportunities violates IRDAI's fair claims handling guidelines.
Available Grievance Redressal Options
Policyholders facing similar situations have multiple recourse options. The first step involves writing to the insurance company's grievance redressal officer. If this doesn't yield satisfactory results, the matter can be escalated to Bima Bharosa or the Insurance Ombudsman.
The case presents several strong arguments in the policyholder's favor: the 2008 condition was medically certified as cured, the current AMAN condition is unrelated, and the five-year moratorium protection might apply. Insurance experts recommend pursuing the grievance process to secure rightful claim settlement.
Shilpa Arora, co-founder and COO of Insurance Samadhan, emphasizes that the duty of disclosure applies only to material facts that are current, ongoing, or likely to affect risk assessment. A remote, fully-resolved condition typically doesn't qualify as material information, especially when supported by medical certification of recovery.
