Non-disclosure is the most used rejection ground in Indian health insurance and one of the most frequently overturned. The deciding factor is almost always the treating doctor's note on date of first diagnosis.
Open any bundle of rejected cashless claims and non-disclosure will be the single largest category. The letter usually reads something like: the insured failed to disclose a pre-existing condition at the time of proposal, and the policy is therefore void ab initio.It is stated as though it were a finding of fact. It is usually an inference, and inferences can be rebutted.What the insurer has to establishNon-disclosure is not simply "the patient had the condition before the policy". To repudiate on that ground the insurer has to show three things together:The condition existed before the proposal date.The insured knew of it — a condition diagnosed after the policy started cannot have been concealed.It was material to the risk being underwritten.Most repudiation letters address only the first, and often only by inference from a line in the discharge summary such as "known diabetic since 8 years". That sentence is routinely typed by a resident from what the patient said in casualty. It is not a diagnostic record.The document that decides the fileIn our experience the single most effective document is a certificate from the treating doctor stating the date of first diagnosis and the basis for it. Not a discharge summary. A signed, separate certificate that says, in terms: the patient was first diagnosed with this condition on this date, on the basis of this investigation, and there is no clinical evidence of the condition before that date.Where the diagnosis genuinely predates the policy, say so — but establish whether the claimed illness is actually related to it. A diabetic who is admitted for a road traffic accident has not made a claim arising out of diabetes.Other documents that carry weightThe proposal form itself. Ask for it. Insurers frequently rely on non-disclosure of a question that was never asked, or that was filled by an agent. If the form was completed by someone other than the proposer, that is a live issue.Prior prescriptions, or their absence. A gap in pharmacy records is meaningful evidence against a long-standing condition.Continuity of the policy. On a policy running many years, the pre-existing disease waiting period has typically expired. Once it has, a pre-existing condition is a covered condition, and non-disclosure at proposal becomes a much weaker ground — particularly where the insurer renewed year after year without query.The part hospitals get wrongA repudiation is answered with a representation, not a reminder. A representation takes each ground in the letter and answers it with a document. If the letter gives three grounds and you answer one, the file stays closed.It also has to go to the right place. A representation emailed back to the TPA claims desk that issued the rejection rarely moves. It belongs with the insurer's Grievance Redressal Officer, with the full trail attached, and with a clear statement of what you want — reconsideration and settlement of the approved amount.When it is genuinely not contestableWe say so, and we say so within two hours. A claim on a policy three months old, for a condition with clear documented treatment two years before the proposal, on a proposal form the insured signed themselves — that is a losing file. There is no point charging a hospital to pursue it.TimelinesA representation to the GRO must be answered in 15 days. If it is not resolved, the Insurance Ombudsman route opens at 30 days. Most reversals we see land in six to twelve weeks from the date the representation goes in, which is usually far sooner than the hospital expects given the file has often already been sitting for months.If you have rejected claims written off in your books, they are worth a second look. Send one to our desk and we will tell you honestly whether it stands up.