Imagine paying health insurance premiums faithfully for years, only to have your claim rejected because of a medical procedure that happened 15 years ago. This is the shocking reality a Mumbai family faced when their insurer denied coverage for a current medical treatment, citing an "undisclosed" surgery from over a decade and a half earlier.
The Case That's Shaking Insurance Trust
The policyholder, who had maintained continuous insurance coverage with the same company, required medical treatment for a condition completely unrelated to their past medical history. However, the insurance company dug deep into their records and discovered a surgical procedure from 15 years prior that hadn't been mentioned during policy purchase or renewals.
Why Insurers Reject Claims Years Later
Insurance companies have the right to investigate claims thoroughly, and non-disclosure of any medical history—no matter how old—can become grounds for rejection. Common reasons for claim denials include:
- Incomplete medical history disclosure during application
- Pre-existing conditions not properly declared
- Medical inconsistencies in documentation
- Procedural errors in claim filing
How to Protect Your Insurance Claims
This case highlights the critical importance of complete transparency when dealing with health insurance. Here are essential steps every policyholder should take:
- Disclose everything during application, even minor procedures
- Maintain detailed medical records including dates and treatments
- Review policy documents carefully during each renewal
- Update your insurer about any new health developments
- Keep copies of all communication with your insurance provider
What IRDAI Guidelines Say
The Insurance Regulatory and Development Authority of India (IRDAI) has established clear guidelines protecting policyholders. Insurers cannot reject claims for unintentional non-disclosure of insignificant medical information, especially when the current treatment is unrelated to past conditions.
Key Takeaways for Policyholders
This Mumbai family's experience serves as a crucial warning for all health insurance customers. The age of a medical procedure doesn't necessarily protect you from claim rejection if it wasn't properly disclosed. Always err on the side of over-disclosure when dealing with insurance applications and renewals.
If you face a similar situation, remember that you have recourse through insurance ombudsman services and consumer courts. Don't accept claim rejections without proper justification and documentation from your insurer.
