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Claim Rejection Due to PED

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23 Aug, 2021 by  Ronak


we had declared past history of a hairline fracture in the left foot during policy issuance, in the current year due to the accident left foot got fractured and was operated on, but the claim got rejected due to PED

is there any chance if we go to the ombudsman for this claim as this was the accidental claim

Health Insurance

2 Answer

Regional Director, Amicus Insurance Broking

Hairline fracture is not a PED. It is not a chronic condition. Usually it resolves by itself with supportive treatment.

You have not mentioned what treatment you have taken for the hairline fracture and whether x-rays taken post treatment have confirmed that the fracture has been completely healed.

If there has been complete healing, then the denial of claim is unjustified and can be challenged. You can represent the matter to the grievance dept., of the insurer for a review. If there is no resolution within 30 days, you can approach the Ombudsman for relief.

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23 Aug, 2021
CEO, Insurance Samadhan

Dear Ronak

Insurance company can not refuse your claim as you had declared hairline fracture unless they hsd put a clause of waiting

period .

Yes , you should contest and request for reconsideration else escalate to ombudsman .

You can also take our help at Insurance Samadhan .


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