Summary
A retired school teacher's LIC health claim was rejected within 7 days of submission, citing non-disclosure of diabetes. The policy had been in force for 8 years. We analyzed the rejection letter, submitted additional medical records from 3 different hospitals spanning 3 years, and demonstrated that the diabetes was a known but controlled condition, not newly developed. The claim was approved in full within 42 days.
How We Solved It
S Situation
58-year-old retired school teacher from Malleshwaram had a pre-existing diabetes diagnosis for 5 years. LIC rejected the claim citing material non-disclosure — diabetes was mentioned in one hospital record but not all.
T Task
Demonstrate that the diabetes was properly disclosed across relevant medical records, not selectively omitted. Prove the rejection was based on an incomplete medical review, not fraud.
A Action
- 1. Collected 3 years of medical records from 4 different hospitals
- 2. Cross-referenced with the original proposal form — diabetes was listed under existing conditions
- 3. Drafted a 15-page appeal letter citing IRDAI Health Insurance Regulations 2016
- 4. Built a timeline showing no symptoms or treatments were hidden
- 5. Escalated to the GRO with specific reference to IRDAI regulations
R Result
LIC's GRO reviewed the case within 12 days and approved the full claim. The approval letter cited incomplete initial review as the reason for reversal.
Lessons Learned
- Always submit complete medical history
- Insurers must review ALL available medical records
- A well-drafted appeal with proper regulation references gets faster responses
- IRDAI regulations protect policyholders
"I was devastated when LIC rejected the claim. Hari Kotian Sir analyzed 3 years of my medical files and found that LIC's own doctor had only looked at one hospital's records. Within 6 weeks, the full amount was in my account."
— I was | Malleshwaram, Bangalore
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