Under IRDAI's Consolidated Master Circular on Health Insurance Business, once a health insurance policy has been continuously renewed for 60 months (5 years)—reduced from the earlier 8-year threshold—no claim can be contestable by the insurer on grounds of non-disclosure or misrepresentation, except in cases of proven, established fraud.
How Insurers Misuse 'Non-Disclosure' Clauses
Many insurers routinely repudiate hospitalization claims by citing hypertension, diabetes, or past outpatient consultations from years ago, even when those conditions have no nexus with the current hospitalization or fall squarely within the moratorium shield.
How to Challenge a Wrongful PED Rejection
- Obtain the treating doctor's certificate clarifying the exact etiology and duration of the ailment.
- Cite the IRDAI Master Circular moratorium clause and Section 45 principles before the Insurer's Grievance Redressal Officer (GRO).
- Escalate to the Insurance Ombudsman if the rejection is not withdrawn within 15 days.