Consumer Forums on Mediclaim Rejections: Key Takeaways for Policyholders
- Sunil Khattri
- Jan 12
- 4 min read
Medical insurance is meant to provide financial security during illness or emergencies. Yet, for many policyholders in India, the most distressing moment comes not at the hospital, but when an insurer rejects a claim, often citing a pre-existing condition. Recent decisions by consumer forums across India show that such denials are not always justified, and that policyholders have stronger rights than they may realise.
Two recent cases highlight a consistent legal principle: insurers cannot deny valid claims merely by alleging a pre-existing disease unless they clearly prove its relevance to the treatment.
The Ahmedabad case
In one such case decided by a consumer forum in Ahmedabad, a policyholder had a valid mediclaim policy and underwent hospitalisation for medical treatment. The insurer rejected the claim on the ground that the insured allegedly had hypertension, which was not disclosed at the time of purchasing the policy.
During the proceedings, however, the insurer failed to establish two essential points:
That the insured had intentionally concealed the condition, and
That hypertension had any direct causal connection with the treatment for which the claim was made.
The forum held that a mere reference to a pre-existing condition is not sufficient. Unless the insurer proves that the condition existed prior to the policy and was medically linked to the treatment, claim repudiation cannot be sustained. The insurer was therefore directed to pay the claim amount along with interest and compensation.
A similar ruling from Rajkot reinforces this principle
This approach was reaffirmed in another case decided by the Rajkot District Consumer Disputes Redressal Forum in December 2025. In this matter, a policyholder’s mediclaim of ₹7.07 lakh was denied by the insurer on the allegation that the insured had failed to disclose hypertension and diabetes.
The claim, however, arose from treatment following a road accident. The forum noted that the injuries and medical treatment resulting from the accident had no nexus with the alleged pre-existing conditions. Since the insurer could not demonstrate any medical relevance between the two, the forum held the rejection to be an unfair trade practice and deficiency in service, and directed the insurer to pay the full claim amount with interest and litigation costs.
Together, these cases reflect a growing judicial consistency: pre-existing conditions cannot be used as a blanket excuse to deny claims, especially when the treatment is unrelated.
Why pre-existing conditions are a common ground for claim rejection
Pre-existing diseases remain one of the most commonly cited reasons for claim repudiation in India. Conditions like hypertension, diabetes, thyroid disorders, or mild cardiac issues are frequently used as grounds for denial, even when the treatment is unrelated.
Many policyholders are unaware that:
Not every past medical condition automatically disqualifies a claim
Insurers must prove relevance, not merely mention non-disclosure
The burden of proof lies on the insurer once a claim is filed
This lack of clarity often leads to fear, confusion, and financial distress for families already dealing with medical emergencies.
What the law says
Indian consumer and insurance law offers important safeguards to policyholders:
Consumer Protection Act, 2019: Insurers can be held liable for deficiency in service if claims are rejected unfairly or without proper evidence.
Insurance principles require insurers to act in good faith and assess claims reasonably.
Consumer forums have repeatedly held that technical grounds cannot override genuine claims, especially when treatment is unrelated to the alleged pre-existing condition.
Courts and forums have also recognised that denial of medical insurance in genuine cases can affect a person’s right to health and dignified life, particularly when the policyholder has acted honestly.
What policyholders should learn from these cases
If you hold a mediclaim policy, this case offers some key lessons:
Disclose medical history carefully while buying insurance, even if a condition seems minor
Ask for written reasons if a claim is denied
Preserve medical records that show the actual cause of treatment
Do not assume rejection is final—review the policy wording
Seek redressal through insurer grievance cells, IRDAI, the Insurance Ombudsman, or Consumer Courts if required
Awareness is the strongest protection a policyholder has.
A broader issue in India’s health insurance system
Claim settlement disputes, particularly those involving pre-existing conditions, form a significant portion of insurance grievances in India. As medical inflation rises and reliance on health insurance increases, transparency and fairness in claim processing become essential to maintain public trust in the system.
Final words
Medical insurance exists to support people during illness and not to add another layer of stress. The Ahmedabad and Rajkot cases clearly demonstrate that insurers cannot deny legitimate claims without proving relevance and intent. For policyholders, these rulings reinforce a vital truth: fairness is enforceable, and unjust denials can be challenged.
Understanding how pre-existing conditions are interpreted, knowing where to seek help, and being willing to question unfair denials can protect families from unnecessary financial hardship. In an evolving insurance landscape, informed policyholders are empowered policyholders.
The Author :
Dr. Sunil Khattri
+91 9811618704
Dr Sunil Khattri MBBS, MS(General Surgery), LLB, is a Medical doctor and is a practicing Advocate in the Supreme Court of India and National Consumer Disputes Redressal Commission, New Delhi.
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