Health claim rejected for non-disclosure — what if I wasn't asked, or didn't know?

A non-disclosure rejection turns on the proposal form: what it actually asked, what was answered, and whether you knew the fact when you signed. Get a copy of the form, compare the exact question with the insurer's allegation, and check whether you have completed 60 continuous months of cover, after which a health insurer cannot contest the policy or a claim for non-disclosure except for established fraud. If the insurer has also cancelled the policy, ask for its grounds in writing.

Non-disclosure means the insurer says something about your health was left out of, or wrongly stated in, the proposal form you signed when you bought the policy. It is a different argument from a pre-existing disease rejection, which is about waiting periods (checking a PED rejection). If the letter mixes the two, answer each one separately.

What you were expected to disclose

IRDAI's policyholder-protection master circular says that if the proposal form asks for health and medical details, the prospect is required to give them, and asks prospects to take due care because the proposal form is the basis on which the policy is issued. The standard Customer Information Sheet format also tells buyers to disclose all pre-existing diseases or conditions before buying.^[1]

A policy wording can back this with a strong condition. One insurer's wording, for example, makes the policy void and the premium forfeited for misrepresentation, mis-description or non-disclosure of any material fact. Notice the word material: the fact has to be one that matters.^[2]

Five questions to test the allegation

1. 1

   Was the question actually asked?

   Insurers must give you a copy of the proposal form with the policy document, free, within 15 days of accepting the proposal. Read the exact question: 'Have you ever been hospitalised?' is not the same as 'Do you suffer from any illness?' If you no longer have the form, see getting a copy of your proposal form.^[1]

2. 2

   Who filled it in, and in which language?

   IRDAI's 2024 policyholder-protection master circular says that if a prospect is not familiar with the language of the proposal form, the insurer or the distribution channel shall explain the details it asks for. If an agent or a bank employee filled in the answers, say so in your reply and attach anything that shows it.^[1]

3. 3

   Did you know the fact when you signed?

   A condition first diagnosed after you bought the policy could not have been disclosed. One insurer's wording also says it will not repudiate the policy on the ground of fraud if the insured can show the misstatement was true to the best of their knowledge, with no deliberate intention to suppress the fact.^[2]

4. 4

   Has the moratorium passed?

   After 60 continuous months of health cover, including ported and migrated cover, the insurer cannot contest the policy or a claim on grounds of non-disclosure or misrepresentation, except for established fraud.^[3]

5. 5

   Does the fact relate to this claim?

   Ask the insurer to explain how the fact it relies on bears on the risk it accepted or on this claim. A rejection must give full details with reference to the specific policy terms, so a bare 'non-disclosure' line is not enough.^[4]

If the insurer has also cancelled the policy

Cancellation and refusal to renew can rest on the same grounds. IRDAI's product regulations allow an insurer to refuse renewal for established fraud, non-disclosure or misrepresentation, and one insurer's wording lets the insurer cancel the policy on those grounds with 15 days' written notice and no refund of premium.^{[3, 2]}

Ask for the cancellation notice and its grounds in writing, and challenge the cancellation in the same complaint as the claim. Under IRDAI's health master circular, the rejection itself needs the approval of the insurer's Product Management Committee or Claims Review Committee. That is an internal step: the circular does not provide for you to appear before it.^[4]

What to send

• The proposal form, marked up: Highlight the question the insurer relies on and the answer given.
• Evidence of dates: Anything that shows when the condition was first diagnosed, especially if that was after the policy began.
• Your explanation: Short and factual: what you knew, who filled in the form, and why the fact does not bear on this claim, if that is your case.
• A clear request: Reconsideration of the claim and withdrawal of any cancellation. The insurer should resolve the complaint within 14 days, with reasons if it does not accept it.^[1]

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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