Health Insurance Claim Rejected Over Alzheimer's and NPH Pre-Existence Allegation Despite No Prior Diagnosis

A family purchased a health insurance policy for their elderly mother, porting it from one insurer to another in early 2022. At the time of porting, the only disclosed medical condition was a gastric ailment. No neurological condition had ever been diagnosed, and no neurological claims had been made under the previous policy.

Several months after the port, the family began noticing changes in their mother's behaviour. She was seen by a doctor, and further evaluation at a specialist centre resulted in a diagnosis of Normal Pressure Hydrocephalus (NPH). More than two years after the policy was ported, a comprehensive assessment led to a formal first-time diagnosis of Alzheimer's disease.

Two hospitalisation claims, each of modest value, were subsequently filed. Both were rejected by the insurer. Shortly after the rejections, the policy itself was terminated.

The insurer's stated basis for rejection centred on wording in hospital discharge summaries. Those documents referenced "abnormal behaviour" stretching back several years before the hospitalisations. The insurer treated this retrospective symptom history as evidence that the conditions pre-dated the policy port, and therefore fell within the pre-existing disease exclusion.

The family contested this reasoning firmly. Discharge summaries routinely capture a patient's reported symptom timeline as part of clinical history-taking. The presence of symptoms in the past is clinically and legally distinct from a formal medical diagnosis. Neither NPH nor Alzheimer's had been named, coded, or treated under the previous policy. The family pointed to a straightforward piece of evidence: if either disease had genuinely existed before the port, claims would have been filed under the earlier policy. None were.

Despite repeated submissions of the same explanations and supporting documents over several months, the family received no substantive reassessment. The burden of proof appeared to have been reversed, with the policyholder required to disprove an assumption rather than the insurer required to demonstrate a prior diagnosis.

This case illustrates a pattern in which insurers conflate symptom onset, which may be gradual and unrecognised, with a clinical diagnosis, which is a specific, documented medical determination. For progressive neurological conditions, behavioural changes can precede any formal diagnosis by years. Using those pre-diagnostic symptoms to invoke a pre-existing disease exclusion, without evidence of an actual prior diagnosis or treatment, stretches the exclusion well beyond its intended scope.

The family has sought recourse through the regulator and the Insurance Ombudsman, asking that the claims be evaluated on medical evidence rather than inferred assumptions drawn from retrospective symptom descriptions.

What went wrong

• The insurer treated retrospective symptom descriptions in discharge summaries as equivalent to a formal pre-existing diagnosis, without evidence that either NPH or Alzheimer's was ever diagnosed or treated before the policy was ported.
• Both hospitalisation claims were rejected without a substantive medical review distinguishing symptom history from clinical diagnosis.
• The policy was terminated alongside the claim rejections, removing all future coverage for a now-confirmed condition.
• The family was made to submit the same explanations repeatedly over several months without receiving a meaningful reassessment.
• The absence of any claims under the previous policy, a strong indicator that no diagnosis existed before porting, was not given adequate weight.
• The burden of proof was effectively reversed, requiring the policyholder to disprove an assumption rather than requiring the insurer to demonstrate prior diagnosis or treatment.

What evidence mattered

• Complete medical records from the period before the policy port date, showing no diagnosis or treatment for NPH or Alzheimer's disease.
• A written certificate or statement from the treating neurologist specifying the date of first formal diagnosis for each condition.
• The previous insurer's claim history confirming no neurological claims were ever filed under the earlier policy.
• The discharge summaries in question, annotated or accompanied by a clinician's explanation that symptom-history language does not constitute a prior diagnosis.
• The original porting documents and declarations submitted at the time of porting, confirming that no neurological conditions were known or diagnosed.
• Correspondence from the current insurer setting out the specific grounds for rejection, to be challenged point by point in any escalation.

The escalation route that applies

1. 1.File a formal written grievance with the insurer's internal grievance redressal officer, referencing the specific rejection grounds and requesting a medical expert review.
2. 2.If the internal grievance is not resolved satisfactorily, register a complaint on the Bima Bharosa (IGMS) portal maintained by IRDAI.
3. 3.If the complaint is not attended to within 15 days of registration on Bima Bharosa, or if the resolution provided by the insurer is not satisfactory, approach the Insurance Ombudsman under the Insurance Ombudsman Rules, 2017.
4. 4.The Insurance Ombudsman is a quasi-judicial body that provides a cost-effective and impartial grievance redressal mechanism. Further information on rules and procedures is available at http://www.cioins.co.in/
5. 5.If the ombudsman route does not yield a satisfactory outcome, consider filing a complaint before the appropriate consumer disputes redressal forum under the Consumer Protection Act.

Solvh's take

This case reveals a well-documented pattern in neurological health insurance claims: the conflation of symptom onset with formal diagnosis. Progressive conditions such as Alzheimer's disease and Normal Pressure Hydrocephalus are, by their nature, characterised by a slow, often unrecognised pre-diagnostic phase. Behavioural and cognitive changes may be noticed by family members long before any clinician assigns a diagnosis.

Discharge summaries are clinical documents, not legal declarations. When a doctor writes that a patient exhibited "abnormal behaviour since several years," they are recording a history given by the family at the time of admission. That narrative serves diagnostic and treatment purposes. It does not constitute evidence that the patient was previously diagnosed with, or treated for, a specific named condition.

The insurer's decision to terminate the policy alongside the claim rejections compounds the concern. Policy termination removes any future protection, which means the family bears both the immediate financial loss and the long-term consequence of being uninsured for a condition that is now confirmed.

The absence of any prior claims under the ported policy is a material fact that a fair review process should have weighed heavily. If a condition were truly pre-existing and symptomatic enough to be denied coverage, it would typically have generated medical consultations and claims under the earlier policy.

From a systemic perspective, this case points to gaps in how some insurers handle ported policies and neurological claims. A robust process would require a medical expert reviewer to confirm that an actual prior diagnosis existed, not merely that retrospective symptoms were documented. Policyholders in this situation should compile all historical medical records from before the port date, obtain written statements from treating physicians clarifying the date of first formal diagnosis, and engage the standard grievance and regulatory escalation channels available to them. If a complaint registered through the IRDAI portal is not resolved satisfactorily, the Insurance Ombudsman provides a cost-effective and impartial grievance redressal mechanism for cases of this kind.