Scenario: a PED rejection where the diagnosis came after the policy started

This walkthrough follows an invented family whose health claim is rejected as a pre-existing disease, although their records show the condition was first diagnosed after the policy began. It shows how they test the insurer's reason against the policy's definition, build a dated timeline from documents, and write a grievance that answers the reason point by point. It does not say how the dispute ends.

Step 1: Test the reason against the definition

Under IRDAI's 2024 Insurance Products Regulations, a pre-existing disease is a condition diagnosed by a physician, or for which medical advice or treatment was recommended or received, within 36 months before the policy started. So the question is not whether the hospital calls the condition 'known' in 2025, but when it was first diagnosed, advised or treated, and whether that date falls in the 36 months before 1 June 2023.^[1]

Check the family's own policy definition too. IRDAI's health master circular required non-complying products to be modified by 30 September 2024, and lets insurers extend the revised benefits to existing policyholders rather than requiring it, so an older product may carry older wording. The policy's UIN and its current wording show which applies.^[2]

The rejection must give details with reference to the specific terms of the policy, and a health claim cannot be repudiated without the approval of the insurer's Product Management Committee or its Claims Review Committee. If the letter names no clause, or rests only on the admission note, the family asks in writing for the clause and for the documents the insurer relied on.^[2]

Step 2: Build the timeline from documents

• The admission note: 'Known case of' records that the condition existed at admission. It does not say when it began, which is what the definition turns on.
• The clinic prescription: The earliest dated record of the diagnosis. If it is undated, ask the clinic for a copy of its register entry.
• Pharmacy and test records: Show when medicine and tests started, which supports or undercuts the date of first diagnosis.
• A doctor's letter: The treating doctor can state, from the records, when the condition was first diagnosed and treated. See what a doctor's letter should cover.
• The proposal form: Shows exactly what was asked and answered. See getting a copy of the proposal form.

Step 3: The grievance letter

1. 1

   Quote the reason

   Copy the insurer's stated reason and clause exactly as written.

2. 2

   Set out the definition

   Quote the policy's definition of pre-existing disease, with its clause number.

3. 3

   Give the dates

   From the timeline: policy start, first diagnosis, admission. One line each, each with a document number.

4. 4

   Answer the 'known case' point

   Explain that the admission note records the condition at admission, and that the earliest record of diagnosis is after the policy began.

5. 5

   Ask for a decision

   Ask the insurer to reconsider the claim, or to give a reasoned decision that refers to the specific policy terms and to any evidence of an earlier diagnosis. IRDAI's master circular says the insurer should resolve a complaint within 14 days.^{[3, 2]}

What would change the analysis

• An earlier record turns up: If a record shows diagnosis, advice or treatment in the 36 months before the policy began, the condition is pre-existing under the definition. The questions then become whether it was disclosed and what waiting period applies; for disclosed pre-existing diseases that period can be at most 36 months of continuous cover.^[1]
• Five years of continuous cover: After 60 continuous months of cover, counting portability and migration, a policy or claim cannot be contested for non-disclosure or misrepresentation except for established fraud. This policy is about two years old, so that protection does not apply here.^[1]
• Earlier cover elsewhere: Ported or migrated cover counts towards those 60 months. See continuous coverage.^[1]
• A specific waiting period: Some treatments have their own specific waiting period, of up to 36 months from the start of the policy, during which they are not covered except after an accident. Check whether the procedure is listed.^[1]

If the insurer maintains the rejection

The family can take the complaint to the Insurance Ombudsman once the insurer has rejected their written complaint, replied unsatisfactorily, or not replied within one month, within the one-year limit that runs from that answer or silence. For pre-existing disease rejections the Council for Insurance Ombudsmen asks for earlier policies covering the 48 months before the current one; here there were none, so the policy's start date and the absence of earlier cover are themselves the point. The eligibility checklist covers the other conditions.^{[4, 5]}

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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