Insurance

Health Insurance Claim Rejected for an Undisclosed Disease? Here's What to Do

A claim rejected for non-disclosure is not always final. After 60 continuous months of cover — including years carried forward through porting — the step-by-step escalation path from the agent through Level 1 and Level 2 grievance emails to the Insurance Ombudsman, and why every old policy document is the proof that makes it work.

21 October 2026 · Raja Banka · RHB Wealth Pro, Salt Lake, Kolkata

A hospital claim gets rejected and the letter says a pre-existing disease was not disclosed. Before accepting that, check the complete policy history — years with a previous insurer, including ones left behind on porting, can matter more than the client realises.

The five-year moratorium, in practice

Once a policy has run for 60 continuous months, the insurer can no longer contest a claim for non-disclosure or misrepresentation — only proven fraud reopens the question, and the burden of proving it sits with the insurer. Porting does not reset this clock. Three years with one insurer plus two with the next still completes the five years; the current policy does not need to be five years old on its own.

Two things it does not do. It does not override exclusions, co-payments, deductibles or sub-limits written into the policy — those still apply. And if the sum insured was increased along the way, the increased portion starts its own fresh 60-month clock from the date of that enhancement, not from the original start date.

Five steps once a claim is rejected

The sequence matters more than any single step — each one exists mainly to create the proof the next one asks for. Here is the path end to end before the detail on each stage:

1. Take the rejection back to the agent first. Ask for the reason in writing, with the exact policy clause cited, and hand over the full policy history — old policies, renewal records, portability letters. A follow-up that spells out total continuous coverage and moratorium eligibility sometimes gets a decision reconsidered on its own.
2. Email the Grievance Redressal Officer — Level 1. Every insurer is required to publish its GRO's name and email address on its own website — look it up there rather than going through a call centre. Email the GRO with the policy number, claim reference and the rejection letter, and ask for a reasoned response against the clause relied upon. Keep that email and any acknowledgement or reference number that comes back — it is the proof the next two stages will ask for. Keep everything in writing; do not rely on calls or verbal assurances.
3. Escalate to Level 2 — still by email. If Level 1 is unresolved, or there is no reply within the timeline the insurer's own grievance policy states, every insurer's grievance page also names a Level 2 escalation — typically a more senior grievance or nodal officer, with its own published email address. Write again, attach the Level 1 correspondence and reference number, and restate the request. This is still an email to the insurer, not a regulator or a portal.
4. Approach the Insurance Ombudsman — but only after Level 1 and Level 2, not instead of them. This becomes available once the insurer's response is unsatisfactory, or a month has passed with no reply. The Ombudsman's office will ask for proof that the insurer's own grievance process was used first — the Level 1 and Level 2 email correspondence and reference numbers. Going straight to the Ombudsman without that proof is a common reason complaints are sent back. File at cioins.co.in, at the office with jurisdiction over the complainant's residence or the insurer's office, not any office of choice. The service is free, the amount sought must be within ₹50 lakh, and the complaint generally needs to be filed within one year of the insurer's rejection of the grievance (or the expiry of that one-month reply window). The same dispute must not already be pending before, or decided by, a court, consumer forum or arbitrator. Attach the current and previous policy schedules, portability records, the rejection letter, medical records and bills, and the full grievance correspondence, with the continuity dates laid out clearly.
5. Read a reduced settlement before accepting it. If the insurer comes back with less than the amount claimed, ask for an itemised break-up and the policy basis for each deduction. Challenge what is not justified and press for the full amount payable under the policy — which is not always the same as the full hospital bill. Check the wording of any "full and final settlement" before signing it.

Why the old policy documents matter more than people think

This is the single biggest point of leverage in a non-disclosure dispute, and the easiest thing to have thrown away. Without the old policy documents, there is no way to show the insurer — or the Ombudsman — that the 60-month clock was already running before the switch. A portability certificate alone is often not enough; keep the full paper trail.

Every year, with every insurer the client has held cover with, keep:

• The full policy document or schedule for that year
• Renewal receipts and premium payment proof
• Portability or migration letters and continuity certificates
• Any correspondence about a change in sum insured

Scan and store these somewhere that survives a change of insurer, a change of agent, or a few years of not thinking about the policy at all. A claim dispute can surface years after a policy has lapsed, by which point the paper copy is usually the one thing nobody can find.

Sources and method

• IRDAI, Master Circular on Health Insurance Business, 29 May 2024, Chapter I, Clause 13 (the 60-month moratorium on non-disclosure and misrepresentation), the provision on a fresh moratorium for an enhanced sum insured, and the requirement that every insurer publish its Grievance Redressal Officer's contact details and escalation levels — IRDAI Health Department.
• Insurance Ombudsman eligibility, jurisdiction and filing procedure — Council for Insurance Ombudsmen: Procedure and FAQs, under the Insurance Ombudsman Rules, 2017.

Questions this raises

Can an insurer reject a health claim for non-disclosure after five years?

No, except where fraud is proven. Once a policy has run for 60 continuous months, including years carried forward through portability, the insurer cannot contest a claim or policy for non-disclosure or misrepresentation, and the burden of proving fraud rests with the insurer.

Does porting to a new insurer reset the moratorium period?

No. If the switch was made without a break in coverage, the time held with the previous insurer counts towards the 60 months. The current policy does not need to be five years old on its own.

How do I complain to my health insurer's Grievance Redressal Officer?

By email, directly to the GRO — IRDAI requires every insurer to publish the GRO's name and email address, and its escalation levels, on its own website. State the policy number and claim reference, attach the rejection letter, and ask for a reasoned response against the clause cited. If Level 1 is unresolved or there's no timely reply, escalate by email again to that insurer's Level 2 officer. Keep every email and reference number — proof of both levels is what the Insurance Ombudsman asks for next.

Should I go straight to the Insurance Ombudsman if my claim is rejected?

No. The Insurance Ombudsman's office expects proof that the insurer's own grievance process — Level 1 and Level 2, both by email — was used first, before it will accept the complaint. A complaint filed without that proof is commonly sent back.

What is the compensation limit and time limit to file with the Insurance Ombudsman?

The amount sought must be within ₹50 lakh, and the complaint is generally filed within one year of the insurer's rejection of the grievance, or the expiry of one month without a reply. Filing is free, at the Ombudsman office with jurisdiction over the complainant's residence or the insurer's office.

What documents should be kept in case a health insurance claim is disputed?

The full policy document for every year and every insurer held, renewal receipts, portability or migration letters, and any correspondence about a change in sum insured — kept well beyond the year the policy was taken, ideally scanned and stored digitally.