Portability and the Stroke
Sanjib Das, 48, bought a family floater health policy with a sum insured of Rs 5,00,000 from Insurer X in July 2020. At proposal he disclosed that he had been on medication for hypertension since 2016. Insurer X accepted the risk at a 10% extra premium; the schedule carries a 24-month waiting period for pre-existing diseases. In June 2023 he applied to port the policy to Insurer Y, whose PED waiting period is also 24 months. The portability form was filed 45 days before renewal and Y issued a fresh policy on 20 July 2023 on the same sum insured, applying a 15% loading and no exclusion. On 3 November 2024 Sanjib was admitted to a private hospital in Guwahati with an acute stroke. The bill was Rs 3,20,000 for five days, including room rent charged at Rs 9,000 a day. Y's policy caps room rent at 1% of sum insured per day and applies proportionate deduction where a higher category room is taken. Y's TPA has rejected the entire claim as a pre-existing disease within the waiting period.
1. Is the TPA's rejection on pre-existing disease grounds sustainable after portability?
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No, the rejection is unsustainable on the stated ground. Portability under the IRDAI (Health Insurance) Regulations 2016 and the portability guidelines is designed to protect continuous coverage. The new insurer must give credit for the period already spent with the previous insurer, and may only require the balance of its own waiting period. Sanjib had more than three years with Insurer X against a 24-month PED waiting period; that period was fully served before 20 July 2023. Insurer Y's 24-month clock started from zero only for genuinely new conditions, not for the disclosed hypertension and its consequences.
Y's own underwriting confirms this. It accepted the risk with a loading and without any exclusion or waiting-period endorsement specific to hypertension or cardiovascular events. Having priced the risk, it cannot later resurrect a waiting period it did not impose.
The stroke. Even if a stroke is treated as a complication of long-standing hypertension, the waiting period for that pre-existing condition had run out. If Y wanted to exclude it, an express exclusion clause with a clear endorsement was required at inception.
Caveat. Y may still examine whether the disclosure in the portability form matched the X records, and whether the 45-day filing was within the portability window. A misrepresentation at portability would be a different ground, but it is not the ground the TPA has taken.
2. Assuming the claim is otherwise admissible, compute the payable amount applying the room-rent proportionate deduction. State the assumption you rely on.
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Room-rent cap. 1% of Rs 5,00,000 = Rs 5,000 per day. Actual charge Rs 9,000 per day for 5 days = Rs 45,000 against an admissible room charge of Rs 25,000.
Method 1 – proportionate deduction across the bill (the usual wording where the insured occupies a higher category): Payable = eligible bill x (cap / actual room rate) = 3,20,000 x (5,000 / 9,000) = 3,20,000 x 0.5556 = Rs 1,77,778 (approx.).
Method 2 – deduction of the room-rent excess only (where the clause says only the excess room charge is deducted): Payable = 3,20,000 - 20,000 = Rs 3,00,000.
The policy wording decides which method applies, and this is precisely the point on which such claims turn. Method 1 has been upheld where the clause says 'proportionate deduction', because a higher-category room normally brings higher surgeon and nursing charges; Method 2 applies where the clause is limited to the room rent.
Further reductions apply for non-payable items (consumables, administrative charges), any co-payment the policy imposes, and the pre/post-hospitalisation limits. The Rs 5,000 per-day figure must also be checked against any ICU sub-limit if part of the stay was in intensive care.
3. What grievance route should Sanjib follow, with timelines, and can he go straight to the ombudsman?
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Step 1 – the insurer. A written complaint to Insurer Y's Grievance Redressal Officer. The insurer must acknowledge within three working days and resolve within 14 days of receipt. The TPA is not a separate party; the insurer is answerable for the TPA's decisions and must give written reasons for a rejection.
Step 2 – IRDAI's IGMS. If there is no reply in 14 days or the reply is unsatisfactory, the complaint can be escalated to the IRDAI Integrated Grievance Management System, which tracks the insurer's response.
Step 3 – Insurance Ombudsman. He may approach the Ombudsman having jurisdiction (Guwahati) if the insurer has rejected the complaint or not replied within 30 days. The complaint must be made within one year of the insurer's rejection, must not be pending before a court or consumer commission, and must be for a claim within the Ombudsman's pecuniary limit – Rs 30 lakh under the Insurance Ombudsman Rules 2017. That limit comfortably covers a Rs 5 lakh sum insured.
Nature of the award. The award is binding on the insurer, which must comply within 30 days; the complainant may reject it within 30 days and pursue remedies before a consumer commission or civil court. The Ombudsman's process is free and does not require a lawyer.