Archive · 2 Nov 2025
Insurance Claim Rejected Over Unrelated 15-Year-Old Surgery
Imagine you have a special savings account that helps pay for when you get sick.
Your husband got sick and went to the hospital, so you asked the savings account company to help pay for it.
But the company said no, even though he was sick with a liver problem.
They looked back many, many years and saw he had surgery on his leg for a different problem a long time ago.
They unfairly said this old surgery was related to his new liver sickness, which doesn't make sense.
Doctors agree that these two problems are not connected.
The rules for these savings accounts say a sickness has to be something you had recently to be considered 'pre-existing.'
You should ask the company why they think these are connected, then tell them their decision is wrong.
If they still don't help, you can ask a special helper, then a bigger helper, and if needed, even go to a judge to get the payment you deserve.
An insurance claim for hospitalization due to chronic liver disease was rejected by the insurer.
The rejection was based on a varicose vein surgery performed approximately 15 years prior, deemed a pre-existing condition.
The insurer claimed a connection between the past surgery and the current liver ailment.
According to IRDAI definitions, a pre-existing disease must have been diagnosed or treated within 48 months before the policy's start date.
The policyholder is advised to demand a detailed rejection letter and escalate the complaint through various grievance redressal channels if unsatisfied.
- Who
- An insurance policyholder and their husband
- What
- An insurance claim for hospitalization due to chronic liver disease was rejected, with the insurer citing an unrelated varicose vein surgery from 15 years prior as a pre-existing condition.
- When
- The hospitalization occurred from July 14-22, 2024. The surgery in question was performed approximately 15 years ago.
- Where
- A reputed hospital (specific location not mentioned)
- Why
- The insurance company rejected the claim, asserting a link between the past varicose vein surgery and the current chronic liver disease, classifying it as a pre-existing condition.
Policyholder's Stance
Insurer's Stance
Pre-existing Condition Classification
Policyholder's Stance
The surgery for varicose veins 15 years ago is unrelated to the current chronic liver disease and does not qualify as a pre-existing condition under the 48-month rule.
Insurer's Stance
The 15-year-old varicose vein surgery is considered a pre-existing condition that is somehow related to the current chronic liver disease, justifying claim rejection.
Medical and Logical Justification
Policyholder's Stance
The insurer's decision is medically and logically unjustified, as varicose veins and chronic liver disease are not connected.
Insurer's Stance
The insurer believes there is a valid medical correlation to justify the claim rejection based on the policy's pre-existing disease clause.
Fairness and Evidence
Policyholder's Stance
Insurers should interpret pre-existing disease clauses with medical evidence and fairness, not based on unrelated past medical histories.
Insurer's Stance
The claim was rejected based on an interpretation of policy terms and conditions concerning pre-existing conditions.
- Policyholder's Husband Hospitalized
- July 14-22, 2024 for chronic liver disease
- Insurance Claim Type
- Reimbursement
- Reason for Rejection
- Claimed relation between current chronic liver disease and varicose vein surgery performed 15 years prior
- IRDAI Definition of Pre-existing Disease
- Diagnosed or treated within 48 months before policy inception
- Policyholder's Next Steps
- Demand clarification, file grievance with insurer, escalate to IRDAI Bima Bharosa, Insurance Ombudsman, or consumer court