Pre-existing disease and non-disclosure
A claim rejected on pre-existing disease means the insurer says the condition existed before the policy began, or was not disclosed when it was bought.
A claim rejected on pre-existing disease means the insurer says the condition existed before the policy began, or was not disclosed when it was bought.
What this ground actually means.
The insurer is saying the condition being treated existed before cover started, or that it was not declared at proposal. Most Indian policies carry a waiting period for pre-existing conditions, commonly two to four years, and a separate duty of disclosure at the time of purchase.
How this ground is actually applied
The insurer is asserting two things at once: that the condition existed before the policy began, and usually that it was not disclosed at proposal. These are separable. A condition can genuinely pre-date the policy and still be payable if it was disclosed and accepted, or if the applicable waiting period has run.
When the condition was first diagnosed or treated, evidenced by a dated record — and what was actually written on the proposal form.
Three things people get wrong about it
“Any old illness makes the whole claim void.”
It affects claims connected to that condition. An unrelated admission is a different question.
“I did not know I had it, so it is not pre-existing.”
Insurers commonly argue from the first dated evidence of the condition rather than from your awareness. Whether that is fair is exactly what a grievance is for.
“The agent filled the form, so I am not responsible.”
The signed proposal is treated as yours. If it was completed by someone else, say so explicitly and early, in writing.
What to check in your own documents
- The date the condition was first diagnosed or treated, and the document that shows it.
- A copy of the proposal form you signed, including the health declaration.
- The pre-existing-disease waiting period in your policy and the date cover started.
- Whether the current admission is clinically connected to the cited condition at all.
- Whether the policy is a port or renewal of an older one, which may carry the earlier start date.
Two sections are missing from this page. The standard policy wording for this ground, and what the Insurance Ombudsman has actually held in published awards. Both are being compiled from the Council for Insurance Ombudsmen’s own reports. Neither will appear here until it can be cited, because a page that invented an award reference would be worse than a page that admits the gap.
The escalation process and deadlines
- The insurer's grievance officer. Response due within 15 days.
- IRDAI Bima Bharosa — bimabharosa.irdai.gov.in — if the insurer does not resolve it.
- The Insurance Ombudsman. Free, no lawyer required, and the award binds the insurer up to the prescribed limit.
- Consumer forum, if you choose to go further.
Ask about your rejection letter
Nothing you type is sent anywhere. Sahayak explains grounds and process — it cannot assess your specific claim or predict an outcome.
Related grounds
Sources
- Council for Insurance Ombudsmen — published awards and annual reports, cioins.co.in
- IRDAI annual report and Bima Bharosa, irdai.gov.in
- Insurance Ombudsman Rules 2017
You do not have to work this out alone.
Sahayak explains the grounds your insurer gave and the official escalation path. It is an information service, not an insurance advisor.