Claim rejected for pre-existing disease (PED) — how do I check if the insurer is right?

Put three dates side by side: when the condition was first diagnosed, or first the subject of medical advice or treatment, when your continuous cover began, and when you were admitted. Under IRDAI's 2024 rules a condition is pre-existing only if it was diagnosed, or advice or treatment for it was recommended or received, within 36 months before the policy started, and the waiting period for a disclosed pre-existing disease can be at most 36 months of continuous cover. If the dates do not fit the insurer's reason, that is the point to put to the insurer in writing.

A pre-existing disease (PED) rejection is a dispute about dates. The insurer is saying two things at once: that your condition existed before the policy began, and that you have not been insured long enough for the PED waiting period to end. Each half can be checked against papers you can get hold of.

What counts as pre-existing

IRDAI's Insurance Products Regulations, 2024 define a pre-existing disease by looking back from the start of the policy. It is a condition a doctor diagnosed within 36 months before the policy began, or one for which medical advice or treatment was recommended or received in that period. A condition first found after the policy started is not pre-existing under this definition.^[1]

The waiting period for a pre-existing disease you disclosed can be at most 36 months of continuous cover, and insurers may offer less. Your policy must state its own period, and the rejection letter must refer to the specific policy term it relies on.^{[1, 2, 3]}

The dates to put side by side

1. 1

   Find the earliest date in the medical record

   Look through old prescriptions, test reports and earlier hospital papers for the first time the condition was diagnosed, or a doctor recommended or gave advice or treatment for it. A discharge-summary line such as 'known case of diabetes' records history; it does not say when the condition was first diagnosed. If the date decides the case, ask the treating doctor to confirm it in writing (what a doctor's letter should cover).

2. 2

   Find when your cover really began

   Your policy must state the date from which you have held health cover continuously without a break. Porting to another insurer carries your waiting-period credit with it, so the clock may have started with an earlier policy, not the current one.^{[3, 2]}

3. 3

   Check the renewals in between

   A renewal paid within the grace period protects your waiting-period credit. A renewal paid after the grace period is a break in policy and can restart the count, so keep every renewal receipt.^{[2, 1]}

4. 4

   Check what you disclosed

   If you declared the condition when you bought the policy, the dispute should be only about the waiting period. If the letter says you did not disclose it, that is a different ground (non-disclosure rejections). One insurer's wording, for example, makes PED cover after its waiting period depend on the condition having been declared and accepted.^[4]

A worked example

The porting credit has limits. It carries over only up to the sum insured and benefits of the previous policy, and if you increased the sum insured, a waiting period can start afresh for the increased part only.^{[1, 3]}

When the moratorium changes the question

After 60 continuous months of cover, counting ported and migrated cover, a health insurer cannot contest the policy or a claim on grounds of non-disclosure or misrepresentation, except for established fraud. Permanent exclusions written into the policy still apply after that point.^{[1, 3]}

What to send the insurer

• The earliest medical evidence: The earliest prescription or report, or a doctor's letter giving the date of first diagnosis, advice or treatment.
• Every earlier policy schedule: Enough to show unbroken cover. The Council for Insurance Ombudsmen asks for old policies covering the 48 months before the current one in PED and waiting-period disputes, so it helps to collect them now.^[5]
• A short written complaint: Quote the insurer's reason, set out your dates, and ask which date of diagnosis, advice or treatment, and which start date, it used. The insurer should resolve a complaint within 14 days and, if it does not accept it, give reasons that refer to the policy terms.^[3]

ClaimAssure is an independent private platform. It is not an insurer, IRDAI, Bima Bharosa or the Insurance Ombudsman, it never files anything on your behalf, and it cannot promise any outcome. What it does is read your documents and show you what they say.

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