Under IRDAI’s definition, a pre-existing disease (PED) refers to any condition that was diagnosed or treated within 48 months prior to the inception of a policy. In simple terms, if a surgery or illness occurred more than four years before you bought your policy — and there has been no ongoing treatment or symptoms — it should not be classified as a pre-existing condition.
In one recent case, a policyholder’s claim was rejected due to a 15-year-old surgery for varicose veins, which had no medical connection to the current diagnosis of chronic liver disease. From both a medical and regulatory standpoint, this reasoning appears unsound. Varicose veins and liver disease are distinct and unrelated conditions, and rejecting a claim on such grounds may amount to unfair claim handling.
Demand Full Clarification
If you face a similar situation, always request a detailed claim rejection letter from the insurer. The letter should clearly state:
- The exact policy clause cited for rejection
- The medical reasoning or expert opinion supporting the decision
- The proofs or evidence linking the old condition to the present ailment
Once received, file a written grievance with the insurer’s Grievance Redressal Officer (GRO). The company must respond within 15 days.
If the response is unsatisfactory, register your complaint on IRDAI’s Bima Bharosa portal, which enables formal regulatory review. Should the matter still remain unresolved, escalate it to the Insurance Ombudsman. As a final step, you can approach the consumer court for deficiency in service or unfair claim rejection.
Why Fair Interpretation Matters
Such cases underline the importance of interpreting the pre-existing disease clause with medical accuracy and fairness, rather than rigid or mechanical assumptions. Health insurance is meant to protect families during medical crises, not penalize them for surgeries or conditions that occurred decades ago.
At Insurance Samadhan, we have helped hundreds of policyholders challenge wrongful claim rejections related to pre-existing disease clauses, room-rent limits, and sub-limits on modern treatments.
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Frequently Asked Questions
No. As per IRDAI, only diseases diagnosed or treated within 48 months before buying the policy are considered pre-existing. A surgery performed 15 years ago, with no recurring symptoms or treatment, cannot be treated as a current pre-existing condition.
Request a detailed claim rejection letter stating the policy clause, medical reasoning, and proof. Then, file a complaint with the Grievance Redressal Officer (GRO) and, if unresolved, escalate the matter to Bima Bharosa or the Ombudsman.
No, they are not. Varicose veins relate to venous insufficiency in the legs, while chronic liver disease affects the liver. There is no direct medical correlation, and one should not be used as a basis to deny a claim for the other.
Insurance Samadhan specializes in assisting policyholders facing claim rejections, delays, or unfair deductions. Our experts analyze the case, draft grievance letters, and guide clients through GRO, Bima Bharosa, and Ombudsman escalation for faster and fairer resolution.
