A health insurance claim of ₹9,92,238 for severe cardiac treatment at EPIC Multispecialty Hospital, Ahmedabad, was rejected by the insurer citing the non-disclosure of hypertension. The Insurance Ombudsman, Ahmedabad, overturned this repudiation, noting the policy had been active continuously since 2013 and had crossed the applicable moratorium period. The insurer was directed to settle the full claim amount along with applicable penal interest.
Case Snapshot.
| Claim Amount | ₹9,92,238 |
| Cover Amount | ₹20,00,000 |
| Diagnosis | Dilated Cardiomyopathy, Cardiac Sarcoidosis, Severe Biventricular Dysfunction |
| Rejection Reason | Alleged non-disclosure of pre-existing Hypertension (HTN) during policy porting |
| Forum | Office of the Insurance Ombudsman, Ahmedabad |
| Outcome | Claim Allowed with Interest |
| Resolution Time | 5 Months |
Background.
Mr. Anand S. Gupta held a continuous health insurance policy since February 7, 2013, initially with a General Insurance Company . The policy was ported to Health Insurance Company on February 21, 2023, maintaining strict continuity, with a total Sum Insured of ₹20,00,000 for the active period of 2024 to 2027.
In April 2025, Mr. Gupta was admitted to EPIC Multispecialty Hospital, Ahmedabad, presenting with severe cough and breathlessness. Medical evaluation diagnosed him with Dilated Cardiomyopathy, Cardiac Sarcoidosis, and Severe Biventricular Dysfunction. He subsequently underwent Cardiac Resynchronization Therapy with a Defibrillator and Left Bundle Pacing Implant. The total hospitalization expenses amounted to ₹9,92,238, for which a formal claim was filed.
Unique Information / Rejection Reason.
The insurer repudiated the total claim amount, alleging that the policyholder suppressed material facts at the time of porting the policy in 2023. Specifically, the insurer cited the non-disclosure of pre-existing Hypertension (HTN) in the proposal form.
It is pertinent to note that Mr. Gupta had explicitly disclosed his history of Diabetes Mellitus during the porting process. The insurer based its rejection entirely on the alleged hypertension, without providing concrete medical evidence that HTN was the sole proximate cause of the complex cardiac conditions.
Documents Reviewed.
To build a factual foundation for the grievance, the following documents were evaluated:
- Original Policy Schedule Previous General Insurance Company from 2013 establishing continuous coverage.
- Portability Proposal Form demonstrating the explicit disclosure of Diabetes Mellitus.
- Current Policy Schedule with Current Health Insurance Company detailing the ₹20,00,000 Sum Insured.
- Medical Records and Discharge Summary from EPIC Multispecialty Hospital.
- The Insurer’s formal Repudiation Letter citing HTN non-disclosure.
Are you facing a claim rejection despite years of continuous policy renewals? Understanding the IRDAI moratorium guidelines can clarify your legal standing. [Link: Read our guide on policy continuity and the moratorium period.]
Legal Analysis / Why the Rejection Was Challenged.
Health insurance principles generally require insurers to substantiate claims of material misrepresentation with direct, verifiable evidence. In this instance, the insurer failed to establish a direct medical nexus between the alleged undisclosed hypertension and the specific cardiac ailments treated.
Furthermore, the policy had remained in force continuously for over 11 years, well past the applicable moratorium period recognized by regulatory frameworks. Once a policy completes the moratorium phase, insurers are strictly restricted from contesting claims on the grounds of non-disclosure or misrepresentation, barring proven, deliberate fraud.
The challenge also highlighted that complex conditions like Dilated Cardiomyopathy are multifactorial. The insurer’s repudiation lacked a justified medical basis tying the entire hospitalization solely to the unproven hypertension.
Strategy Adopted & Outcome.
A formal complaint was filed before the Office of the Insurance Ombudsman, Ahmedabad, focusing on the policy’s continuous coverage since 2013 and the lack of a causal link justifying the repudiation. The matter was officially heard on May 6, 2026.
After evaluating the medical records, policy terms, and the prolonged continuity of coverage, the Ombudsman held that the insurer’s repudiation was not justifiable. The Ombudsman allowed the complaint in favor of Mr. Gupta.
The insurer was directed to pay the claim amount of ₹9,92,238, subject to standard policy deductions and co-payments. Additionally, the insurer was ordered to pay applicable interest under Rule 17(7) of the Insurance Ombudsman Rules, 2017, for the delay in settlement.
FAQs
Can a health insurance claim be rejected for non-disclosure after several years?
Once a health insurance policy completes the IRDAI-mandated moratorium period (5 continuous years or 60 months of renewals), insurers cannot reject a claim for non-disclosure or misrepresentation, except in cases of established fraud.
What is the burden of proof for an insurer alleging misrepresentation?
Insurers must provide concrete, documented evidence (such as prior medical consultation records) to prove that the policyholder was aware of and intentionally concealed a pre-existing condition before the policy inception.
Does an undisclosed illness automatically invalidate a claim for a different disease?
Not automatically. Insurers generally need to establish a direct medical nexus between the undisclosed condition and the current hospitalization to justify a repudiation on those grounds.
What are the Insurance Ombudsman Rules, 2017 regarding delayed payments?
Under Rule 17(7) of the Insurance Ombudsman Rules, 2017, an insurer may be directed to pay penal interest on the claim amount if they fail to settle a justified claim within the stipulated regulatory timeframe.
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