You can file a consumer complaint within 2 years. You can consult me through kaanoon  I will assist you.

If your insurance claim has been rejected by insurance company and Omdusman you have to approach consumer forum fir necessary reliefs 

you have to prove that you have not suppressed  any material facts 

For rejected health claims citing a wrong pre-existing disease, send a formal written appeal to the insurer with all medical records and previous claim proof showing no pre-existing condition. If denied, escalate again to the IRDAI Ombudsman with complete documentation. If unresolved, consider legal help to challenge wrongful rejection.

Dear Client, the insurance provider denied your health claim on the basis of “pre-existing disease" notwithstanding the insurer had previously authorized the claimant's health issue and there was medical evidence to confirm the claimant did not have a pre-existing disease condition, therefore, you could immediately file an appeal for the wrongful denial of your claim. You should start by sending a legal notice to the insurer, requesting payment with interest, citing a breach of the IRDA (Protection of Policyholders' Interests) Regulations, 2017. If there is no positive response from the insurer, you will file a consumer complaint with the District Consumer Disputes Redressal Commission, under the Consumer Protection Act, 2019, for the claim amount, interest, and damages for mental torture as well as deficiency of service. You should provide the previously approved claim documents, the doctors credentialed opinion, the rejection letter, and correspondence with the IRDA. Even if there is a lack of response from the ombudsman, the consumer forum will still have jurisdiction to award damages. I hope this response is helpful. Please follow up with me for any questions.

- This is an usual approach by the Insurance Company to reject the claim on the ground of pre-existing disease

- Send a legal notice to the said company , and if no positive response then file a complaint before the Consumer forum 

You first issue a legal notice to the insurance company demanding the claim amount, if they still deny the claim for the same reason, you can approach consumer commission with a complaint for deficiency in service as well as for unfair trade practice and demand insurance claim amount along with compensation for the mental agony too along with the litigation costs. 

File a case in Consumer Forum against the Insurance Company.

Understanding the Insurance Company's Likely Argument

The insurer is essentially claiming that the condition for which you were hospitalized existed before the inception of your current policy period. Even though it was identified in 2022, if your policy was renewed after that date, they are now classifying it as a "Pre-existing Disease" (PED) from the point of renewal.

However, their position is weak because:

1. Previous Approval: They had full knowledge of the condition from the 202 claim and still chose to renew your policy, likely without an exclusion or a loading (extra premium).

2. Hospital Error: The "erroneous" note from the duty doctor is being used as a convenient excuse to deny a legitimate claim.

Your goal is to systematically dismantle their argument.

Step-by-Step Action Plan

Follow these steps in order. Document every single communication (dates, names, reference numbers).

Step 1: Formal Internal Appeal with the Insurance Company

Do not rely on previous calls or emails. You need to file a formal, written appeal/complaint.

• Channel: Send a physical letter via Registered Post/Acknowledgement Due and an email to the official customer service and grievance redressal addresses of the insurance company.

• Subject: Formal Appeal against Claim Rejection - Policy No: [Your Number], Claim No: [Your Number]

• Content: Your letter must be clear, factual, and reference all evidence. Structure it like this:

  • Background: State the policy number, claim number, date of hospitalization, and the condition treated.

  • The Error: Clearly state that the "pre-existing disease" remark in the discharge summary was an error made by the duty doctor who was unaware of the complete patient history. Attach a corrected medical certificate from the treating specialist or the hospital's Medical Superintendent stating this clearly. (This is crucial).

  • The Contradiction & Estoppel: This is your legal punch. Write something like:

    "We wish to bring to your attention that the same medical condition was first identified and treated in [Month, Year].
    A claim for that hospitalization (Claim No: [Previous Claim Number]) was duly submitted and settled by you.
    At the time of policy renewal subsequent to that claim, no exclusion was applied, nor was any additional premium loaded for this condition. By renewing the policy and accepting premiums, you have implicitly accepted the risk associated with this condition. You are now estopped from denying the claim on the grounds of it being pre-existing, as you were fully aware of its existence."

  • Resolution Sought: Clearly state that you expect the claim to be reviewed and settled within 30 days, failing which you will be compelled to approach the Insurance Ombudsman for redressal.

• Attachments: Include copies of:

  • Current claim rejection letter.

  • Discharge summary from the recent hospitalization.

  • Corrected certificate from the hospital.

  • Previous policy documents, claim form, and proof of settlement for the 2022 claim.

Give them 30 days to respond from the date of your email/letter.

Step 2: Re-approach the Insurance Ombudsman (The Correct Way)

You mentioned you already escalated to the Ombudsman but didn't get a great response. It's possible the complaint wasn't framed powerfully enough. The Ombudsman is a very effective forum, but your presentation matters.

• Refile Your Complaint: Go to the official IRDAI Integrated Grievance Management System (IGMS) - https://igms.irda.gov.in/ or the portal of the specific Ombudsman for your region.

• Strengthen Your Submission:

  • Consolidated Evidence: Submit a single, well-organized PDF containing all the documents from Step 1.

  • Timeline: Create a simple, point-by-point timeline of events:

    1. [Date]: First diagnosed with [Condition].

    2. [Date]: Claim for above approved by [Insurance Co.] (Claim No: XYZ).

    3. [Date]: Policy renewed for the year [Year].

    4. [Date]: Hospitalized again for the same condition.

    5. [Date]: Claim wrongly rejected citing "Pre-existing Disease."

  • Clear Argument: In your complaint description, use the same "estoppel" argument from your internal appeal letter. State clearly: "The insurer is acting in bad faith by approving a claim for a condition and then, upon recurrence, labelling the same known condition as 'pre-existing' to avoid liability."

Step 3: Escalate to IRDAI Directly

If the Ombudsman does not rule in your favor or drags its feet, the next step is to escalate to the national regulator.

• IRDAI Grievance Redressal Channel: File a complaint on the IRDAI's official grievance portal. This puts direct pressure on the insurer as the regulator monitors these complaints closely.

• Clearly State: "The Insurance Ombudsman has failed to provide adequate relief despite a clear case of bad faith and contradiction by the insurer."

Step 4: Legal Notice and Consumer Court

This is your final and most powerful recourse.

• File a Complaint in the Consumer Disputes Redressal Commission: The amount involved (the claim value) is likely well within the jurisdiction of the District or State Commission. This is a faster and less expensive process than a civil court.

• Grounds for Complaint:

  1. Unfair Trade Practice: The insurer's actions are deceptive and unfair.

  2. Deficiency in Service: Wrongfully rejecting a valid claim.

  3. Lack of Good Faith (Uberrimae Fidei): While this doctrine applies to the customer, the insurer's behavior of accepting a claim and then denying the same is a breach of the principle of reciprocity.

• Why you have a strong case: Consumer courts in India have consistently ruled against insurers who reject claims for conditions that were known and accepted by them at the time of renewal. Your evidence from 2022 is your silver bullet.

Summary of Key Actions

1. Get a Corrected Certificate: This is your #1 immediate task. Get a written, signed, and stamped document from the hospital rectifying the duty doctor's erroneous note.

2. Formal Appeal to Insurer: Send a powerful, evidence-backed appeal using the "estoppel" argument.

3. Re-file with Ombudsman: Present a stronger, more organized case with a clear timeline and all evidence.

4. Escalate to IRDAI: If the Ombudsman is ineffective.

5. Consumer Court: The ultimate weapon, where your chances of success are very high given the facts.

Do not get discouraged. Insurance companies often reject claims hoping the customer will give up. Your persistence, backed by the solid evidence of the previous claim, will almost certainly lead to a favorable outcome.

In your case, since the same insurer earlier approved a claim for the same condition, the current rejection citing “pre-existing disease” is legally untenable. Here’s what you can do, concisely:

Send a written representation to the insurance company’s grievance officer enclosing past claim approval (2022) and doctor’s clarification that no pre-existing disease exists.

If no satisfactory response within 15 days, file a complaint before the Insurance Ombudsman (again, if not already done);  attach all medical records, discharge summary, and previous claim proof.

If Ombudsman fails to act, approach the Consumer Court (District Consumer Disputes Redressal Commission) under the Consumer Protection Act, 2019 for deficiency in service and unfair trade practice.

You can seek:

Claim amount with 12% interest,

Compensation for harassment, and

Litigation cost.

Consumer court is the strongest remedy here.

Dear Sir,

• File a Consumer Complaint under Section 35 of the Consumer Protection Act, 2019 before the District Consumer Disputes Redressal Commission.

• Claim:

  • Reimbursement of the rejected claim amount,

  • Compensation for harassment and mental agony,

  • Litigation costs.

Your grounds should include:

• Arbitrary repudiation without medical basis,

• Contradiction with past settled claim,

• Negligence and deficiency in service by insurer and TPA,

• Violation of IRDAI guidelines and fair practice norms

Since the same insurer had earlier approved and settled your claim in 2022 for the same medical condition, they cannot now deny coverage for that very condition under the pretext of it being pre-existing. The acceptance of the earlier claim effectively means the insurer had already verified the illness, medical records, and policy terms before approving the claim. Hence, the present rejection appears arbitrary and in violation of the principles of fairness under the Insurance Regulatory and Development Authority of India (IRDAI) guidelines.

In such a scenario, your next steps should be as follows:

First, send a formal written representation to the Grievance Redressal Officer of the insurance company. The representation should include copies of all relevant documents — policy papers, earlier approved claim records from 2022, current claim rejection letter, discharge summary, treating doctor’s clarification that no pre-existing illness existed, and any hospital communication correcting the erroneous entry made by the duty doctor. Clearly state that the insurer had previously accepted liability for the same illness and that the current rejection is therefore inconsistent and arbitrary.

If you have already raised this grievance and the insurer has not resolved it satisfactorily, you can file a detailed complaint before the Insurance Ombudsman having jurisdiction over your area. You mentioned you have already escalated it to the Ombudsman and IRDAI; however, if the Ombudsman’s decision was not in your favour or if no satisfactory hearing was given, you may take the matter further to the Consumer Commission (District or State level, depending on claim amount).

The Consumer Forum is empowered to review such insurance disputes independently. You can file a complaint under Section 35 of the Consumer Protection Act, 2019, against the insurer for deficiency in service and unfair trade practice. In your complaint, you should include the following grounds:

• The insurer had earlier admitted the same ailment as covered and cannot now deny it as pre-existing.

• The rejection is based solely on an erroneous hospital remark, which has already been clarified by the doctor in writing.

• The insurer failed to verify the accuracy of that remark before rejecting the claim, violating the IRDAI (Protection of Policyholders’ Interests) Regulations, 2017.

• The insurer has acted in bad faith by ignoring past claim history and medical clarification.

Attach all documentary evidence — the previous approval letter, discharge summaries, rejection communication, the doctor’s correction note, and proof of correspondence. You may also include a medical opinion stating that the current illness is not pre-existing.

Before approaching the Consumer Forum, you may also write a final letter to IRDAI’s Grievance Cell (through the IGMS Portal) summarising all your attempts to get redress and requesting intervention. Even though IRDAI itself does not adjudicate monetary disputes, a copy of your IGMS complaint often compels the insurer to review its position more carefully.

If the amount is substantial and you wish to proceed efficiently, consider engaging a lawyer experienced in insurance claim disputes to draft your consumer complaint. The case typically takes around six months to one year for disposal at the District level, depending on your jurisdiction.

You have strong grounds because (a) there is a prior precedent of claim approval for the same disease, (b) there is documentary proof from the treating doctor negating the pre-existing condition, and (c) the insurer’s rejection appears to violate the IRDAI mandate for transparent and fair claim settlement.

You may also include in your complaint a prayer for compensation for mental agony and litigation costs in addition to the claim amount and interest.

If you would like, I can prepare for you a draft consumer complaint and a representation format to the insurance company/IRDAI based on your case documents so you can file it.