Senior Citizen Health Claim: 22 Lakh Approved for 72-Year-Old with Pre-Existing Conditions
A 72-year-old retired banker's claim for hospitalization was rejected by Star Health citing pre-existing hypertension and age-related exclusions. The policy had a 2-year waiting period that was completed. We proved the condition was declared at proposal and the waiting period was satisfied. Full 22 lakh approved within 38 days.
The Situation
72-year-old retired banker from Jayanagar hospitalized for cardiac issue. Policy active for 4 years — waiting period completed. Star Health rejected citing 'pre-existing hypertension' and 'age-related risk' despite hypertension being declared at proposal.
The Challenge
Prove the pre-existing condition was declared and waiting period satisfied. Overturn age-based rejection which is prohibited by IRDAI.
How We Solved It
- Retrieved original proposal form — hypertension declared in medical history
- Confirmed 4-year policy tenure — 2-year waiting period completed 2 years ago
- Cited IRDAI Health Insurance Regulations 2016: no age-based claim rejection after waiting period
- Obtained cardiologist's letter confirming current issue unrelated to declared hypertension
- Filed appeal with GRO referencing IRDAI circular on senior citizen protections
The Result
Star Health GRO approved full 22,00,000 within 38 days. Reversal letter acknowledged waiting period was satisfied and age cannot be a rejection ground post-waiting-period.
Key Lessons
- Waiting period completion makes pre-existing conditions coverable
- IRDAI prohibits age-based claim rejection after waiting period
- Declared conditions at proposal = covered after waiting period
- Senior citizen policies have specific regulatory protections
Client Testimonial
"At 72, I thought my claim was hopeless. They said 'old age' and 'pre-existing'. Hari Sir showed them the waiting period was done 2 years ago. Got my 22 lakh in 5 weeks."