Can your health claim be rejected? IRDAI’s 5‑year moratorium rule explained
Do you have health insurance? Are you confident that your health insurance claim will be cleared in case you need it? You must have clarity on these questions, as the possibility of claim rejection remains one of the biggest fears among health insurance buyers.
To address this concern effectively, the Insurance Regulatory and Development Authority of India (IRDAI) reduced the health insurance moratorium period from eight years to five years in 2024. Still, this rule is often misunderstood and overlooked.
What needs proper acknowledgement?
The moratorium rule does not mean insurers must approve every claim after the five-year period. This is a rule that is designed to defend and protect the rights of health insurance policyholders from claim rejection due to genuine, unintentional non-disclosure made while purchasing the policy.
That is why, as a well-aware health insurance policy holder, you need to establish and build clear communication with your health insurance provider, discuss with them about the moratorium period and understand how you can make the most of your health insurance policy.
Key facts about the health insurance moratorium rule
Health Insurance Moratorium Rule | What It Means for Policyholders |
|---|---|
| Moratorium Period | Reduced from 8 years to 5 continuous years |
| Continuous Coverage | Policy must remain active without renewal breaks |
| Portability Benefit | Previous insurer’s years are counted during porting |
| Genuine Miss Protection | Minor forgotten disclosures may not trigger rejection |
| Fraud Exception | Intentional concealment can still lead to claim rejection |
| Increased Sum Insured | Fresh 5-year moratorium applies only to the enhanced amount |
For example, forgetting or failing to mention a minor acidity issue, slightly high blood pressure or insignificant or borderline thyroid reading years ago may be treated as a ‘genuine miss’; in all such cases, insurers are expected to give policyholders the benefit of doubt after the moratorium period ends.
However, purposefully hiding serious medical conditions, illnesses such as diabetes, cancer, long-term treatments or earlier hospitalisations is considered a deliberate fraudulent concealment of material facts.
Insurers can investigate insincerity on the part of the policyholder by reviewing medical records, prescriptions, medical history, diagnostic reports and even payment trails linked to doctor consultations. If fraud is established, claims can still be rejected and policies may even be terminated.
In summary, the moratorium rule has evolved to protect sincere and honest policyholders. It is not intended to reward intentional or deliberate misrepresentation. As a policyholder, you should acknowledge the fact that health insurance works on the principle of utmost good faith, where complete disclosure continues to remain the most prudent and safest way to secure long-term financial protection and peace of mind.
Can your health insurance claim still be rejected after 5 years?
Therefore, even after five years of devoted health insurance premium payments, your health insurance claims can be rejected if fraud is established or you purposefully hide a serious illness. These rules highlight the importance of honesty, transparency and clarity for policyholders and health insurance providers, which are indispensable to building trust and creating a healthy ecosystem of seamless health insurance approvals.