When you invest in health insurance, you expect peace of mind — not frustration. Yet, that’s exactly what one family experienced when their health insurance claim was rejected because of a surgery that took place 15 years ago.
Let’s unpack why this decision was unfair, medically unsound, and technically incorrect — and how you can protect yourself from similar situations.
The Unfair Health Insurance Claim Rejection
In 2024, a policyholder’s husband was hospitalized for chronic liver disease (CLD). The family filed a claim expecting coverage.
However, the insurer rejected the claim, linking it to a varicose vein surgery that happened 15 years earlier.
From a medical standpoint, varicose veins and liver disease are unrelated. Connecting the two defies both logic and medical reasoning.
According to IRDAI (Insurance Regulatory and Development Authority of India), a pre-existing disease refers to a condition that was diagnosed or treated within 48 months before policy inception. Anything beyond that period cannot be classified as a pre-existing condition.
Hence, the insurer’s rejection was unjustified and violated IRDAI’s own definition.
Where Policyholders Often Go Wrong
Most people assume that once they buy health insurance, their medical bills will be covered without question.
But the reality is more complex — and many policyholders only discover this during a claim rejection.
Key pitfalls include:
- Misunderstanding terms like pre-existing conditions, waiting periods, and exclusions
- Failing to update health declarations over time
- Overlooking minor policy clauses that can have major claim implications
This is where an insurance advisor becomes invaluable.
Why Having an Insurance Advisor Prevents Claim Rejection
An experienced advisor does much more than help you choose a plan. They act as your guide, educator, and advocate, ensuring your policy works for you — not against you.
Here’s how they help:
- Decode complex clauses so you clearly understand what’s covered
- Ensure complete medical disclosures to avoid disputes later
- Recommend the right plan for your current health and financial needs
- Support you during claims — including appeals, escalations, or approaching the Insurance Ombudsman if necessary
- Review and update your policy regularly as your needs evolve
In the case above, a proactive advisor could have challenged the insurer’s reasoning, requested medical justification, and guided the family in filing a grievance through Bima Bharosa or the IRDAI Grievance Redressal Mechanism.
The Bigger Picture: Restoring Trust After a Claim Rejection
Health insurance should be a safety net, not a source of stress.
When insurers misuse clauses to deny unrelated claims, it erodes public trust in the entire system.
The solution lies in:
- Awareness – knowing your rights and reading your policy carefully
- Expert guidance – working with licensed advisors who prioritize your interests
Having an advisor isn’t a luxury — it’s essential protection against unfair health insurance claim rejections.
What You Can Do
Here are simple steps to safeguard your coverage:
- Review your policy every year to ensure it reflects your current health needs
- Update disclosures after major health or lifestyle changes
- Understand exclusions and waiting periods clearly before signing
- Compare coverage, not just premiums, when buying or renewing
- Keep medical and policy records organized for faster claims
Final Thought: Connect with EnrichWise Insurance
A health insurance claim rejection can be emotionally and financially draining — but it doesn’t have to be your story.
At EnrichWise Insurance, we help families make informed insurance decisions — from choosing the right coverage to standing by your side during claims.
Our expert advisors ensure clarity, compliance, and confidence every step of the way.
Connect with EnrichWise Insurance today — and let’s make sure your health policy protects you, not penalizes you.
Because in the world of fine print, EnrichWise stands for trust, transparency, and true protection.