You Bought Health Insurance — Do You Know Your Rights?

This isn’t due to carelessness—it reflects how policy documents are written in dense jargon, full of exclusions, footnotes, and ambiguous clauses. As a result, even educated policyholders are often unaware of what they’re entitled to — or worse, misled into accepting claim denials they could legally contest.

🚨 Why Policyholders Remain in the Dark

According to numerous court rulings, the root problem is information asymmetry: insurers know every clause, while buyers rarely do. This lack of transparency leads to:

• Confusion over claim rejection criteria
• Misunderstanding of waiting or moratorium periods
• Unawareness of portability and renewal rights

Let’s explore real-life cases that highlight why knowing your rights can mean the difference between reimbursement and rejection.

⚖️ Real Cases, Real Lessons

1. Cataract Surgery Denied, Then Reversed (Niva Bupa/Max Bupa)

In April 2025, a 72-year-old woman from Hyderabad had her cashless cataract surgery claim rejected for “non-disclosure” of past health conditions. But she had undergone a full medical exam before buying the policy, and the cataract was unrelated to her prior heart/blood pressure issues.

The District Consumer Forum ruled in her favour, citing the three-year contestability clause under the Insurance Act—after which insurers cannot reject claims based on pre-existing conditions.
Verdict: ₹94,584 reimbursement + ₹20,000 in compensation.
📝 Lesson: After 3 years, insurers cannot cite past ailments unless there was deliberate fraud. Don’t be intimidated—stand your ground.

2. Alcohol Misuse = Claim Rejected (LIC Jeevan Arogya)

In March 2025, the Supreme Court upheld LIC’s decision to deny a claim after a man died of alcohol-related liver disease. The insured had falsely answered “No” to alcohol use in the policy proposal form.

The court found this omission to be material non-disclosure—a legal reason to void the policy.
📝 Lesson: Always disclose lifestyle habits truthfully. Hiding information, even unintentionally, can invalidate your entire coverage.

3. Claim Denied for Late Filing — Then Paid (United India)

In a 2015 case, Harish Dadia from Mumbai was hospitalized for three months after an accident but delayed notifying his insurer. United India denied his claim due to “late intimation.”

The Consumer Forum ruled this was an unfair denial, as Dadia filed the claim in good faith and with valid medical reasons.
📝 Lesson: Notify insurers promptly after hospitalization. If delayed for a legitimate reason, seek redress through grievance channels or forums.

4. Waiting Period Confusion Costs ₹1.3 Lakh (Uttarakhand)

Sachin, a buyer of a family floater policy, filed a claim for his wife’s hysterectomy within the first year. Initially approved by the local forum, it was overturned by the State Commission, which found a one-year waiting period for such surgeries.

📝 Lesson: Always read the fine print. Specific treatments often have waiting periods. Ask for clarity and keep documentation.

5. Chemotherapy vs. Immunotherapy – A Mislabelled Rejection

A cancer patient named Om had his claim denied after a chemotherapy session was wrongly labelled as “immunotherapy” (not covered under his plan). His wife escalated the case to the Insurance Ombudsman.

The Ombudsman reviewed the prescription and discharge documents—which clearly said “chemotherapy”—and ordered full reimbursement.
📝 Lesson: Accurate and complete paperwork is crucial. If wrongly denied, escalate with evidence to the Ombudsman.

🧾 What Are Your Rights as a Policyholder?

Whether you’re dealing with a cashless hospital claim or a reimbursement post-discharge, you are protected under IRDAI rules. Here’s what every policyholder should know:

1. Right to Clear Pre-Sale Disclosure:
   Agents must explain coverage, exclusions, sub-limits, and waiting periods in plain language before selling the policy.
2. Right to Grace Periods & Renewal:
   You get a 15–30 day grace period after the premium due date. Once renewed, moratorium clauses kick in—insurers can’t deny claims for pre-existing illnesses after 2–5 years.
3. Right to Appeal Rejection:
   Every claim rejection must cite specific policy clauses. You can escalate first within the insurer, then to the Insurance Ombudsman or the Consumer Forum.
4. Right to Timely Redressal:
   Insurers are mandated to resolve grievances within 30 days of filing.
5. Right to Portability:
   You can switch insurers during renewal without losing waiting-period credits for pre-existing conditions.

🧠 How to Protect Yourself

• Read every clause: Especially waiting periods, exclusions, and disease-specific sub-limits.
• Disclose everything honestly: Lifestyle choices like alcohol, smoking, or past treatments matter.
• Act quickly: Always notify insurers at the earliest after a hospitalization or treatment.
• Keep documents safe: Retain discharge summaries, test reports, doctor’s notes, and communication trails.
• Escalate smartly: Use your insurer’s grievance portal, Bima Bharosa, or the IRDAI Ombudsman system.

✊ Empower Yourself: Insurance is a Contract of Trust

Insurance is meant to protect, not confuse. Yet too often, policyholders face unnecessary obstacles from the very institutions meant to support them. That’s why awareness is power.

Let this be your reminder to read, question, and assert your rights. Because when it comes to health insurance, knowledge isn’t just power—it’s protection.