Health insurance during pregnancy: When unrelated illnesses can lead to claim rejection

When Anjana Varma (name changed) was hospitalised in April 2024 with high fever —hyperpyrexia in medical parlance—chills, headache and delirium, she expected her health insurance policy to cover the treat ment. Instead, her insurer rejected the claim under the ‘permanent exclusion’ clause, which excludes treatment for pregnancy and related complica tions. The insurer contended that her condition was a complication of LSCS (Lower Segment Caesarean Section), and therefore, fell under the policy’s maternity exclusion clause. Typically, pregnancy and related expenses are not payable unless the product includes maternity cover or you have purchased an optional add-on benefit.

Varma decided to approach the in surance ombudsman, which directed the insurer to review the claim. She challenged the merits of the insurer’s interpretation, asserting that her primary symptoms were high-grade fever, chills, altered/irregular speech and headache, and that the medical records should be evaluated in their entirety before applying the maternity exclusion. “The insurance company was asked to determine (once again) whether the treatment was related to childbirth complications or con stituted standalone treatment. The insurer was further directed to settle the claim, if found payable and admis sible, in accordance with the policy terms within 30 days. The claim was eventually paid,” says Shilpa Arora, Co-founder and Chief Operating Officer, Insurance Samadhan, a firm that assists policyholders in resolving their grievances.

Unrelated ailments

Given that pregnancy lasts around nine months, a woman may require treatment for unrelated ailments during the time, despite exercising requisite care. And determining whether the illness requiring hospitalisation is related to the pregnancy can be a grey area, leading to disputes.


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Take, for instance, the case of Varsha Kapoor (name changed) who had undergone treatment for a gastrointestinal infection during her pregnancy. “She was also diagnosed with severe hyperemesis gravidarum (nausea, vomiting associated with pregnancy) concurrently, which led the insurer to reject the hospitalisation claim citing exclusion of pregnancy-related complications under her policy, which was a regular health insurance plan without mater nity coverage,” says Mayank Gosar, CEO, Softcon Capital, a Mumbai-based investment and insurance advisory firm. To be sure, these expenses would have been straightaway payable had the policy featured built-in maternity cover or a rider add-on.

“Such situations raise complex questions that have no easy answers. At the insurance company’s end, the calls on whether such claims are admissible are taken by expert panels of doctors who are specialists in their respective fields,” says industry veteran Nilesh Sathe, former member, Insurance Regulatory and Development Authority of India (IRDAI). For example, an ophthalmolo gist may detect an eye infection during a cataract procedure (not covered by health policies for the first 6 months to 2 years, depending on the company and the product variant). “While treatment for a standalone eye infection may be covered, the insurance company’s doctors may take the view that the cataract itself may have caused the infec tion,” adds Sathe. Do note that the IRDAI has directed insurance companies not to contest claims or policies after 60 months of continuous coverage on the grounds of non-disclo sure, except in cases of established frauds.

What is clearer is that insurers generally do not cover complications arising directly from a non-covered disease or treatment. “If the primary condition or procedure is explicitly excluded from the policy, any complications, side effects, or treatments that can be traced to that condition will also be denied,” says Arora. For example, pregnancy is not covered under regular retail policies; in fact, even the products that do extend maternity coverage do so after a waiting period up to three years. Likewise, certain procedures, such as cataract and hernia surgery, are admissible after waiting periods of up to two years, while procedures related to cosmetic and dental treatment are typically permanently excluded under regular policies.

Gosar says that if an excluded health condition overlaps with other ailments, there is a high chance that the claim may be rejected. For example, if a woman with a health policy that does not come with an embedded maternity cover were to develop an ailment during her pregnancy, the claim settlement will depend on whether the insurer establishes a connection between the illness/condition and the pregnancy.

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Pregnancy, unrelated illnesses and health insurance

The grey area

*Pregnancy excluded unless policy comes with maternity cover

*Related complications also typically not covered

*But, even non-pregnancy-linked ail ments can face scrutiny

Your best defence: Foolproof medical records

*Check if the diagnosis is clearly re corded

*Records should establish the ailment was not pregnancy-related

*Review discharge summaries carefully

*Correct errors, if any, before leaving the hospital

*Preserve all reports, prescriptions and test results

If your claim is still rejected…

*Understand the insurer’s rationale for rejection

*Obtain your doctor’s note confirming unrelated illness

*File a written appeal with the insurer

*Escalate the matter to the insurer’s grievance officer

*Lodge a complaint via IRDAI’s Bima Bharosa portal

*If not satisfied, approach the Insurance Ombudsman

*Consider consumer court as a last resort

Medical paper trail the key

Therefore, the decision on the claim will boil down to how robust your treatment case papers and hospitalisation records are. “If the treatment is genuinely for a separate and unrelated medical condition, there is a pos sibility of coverage. However, the hospital documentation and the treating doctor’s diagnosis become extremely important in establishing that the condition being treated is independent and unrelated to the excluded ailment,” points out Gosar.

Precise and foolproof medical documentation is the strongest defence against rejection of claims unrelated to pregnancy during the period. “If the doctor’s docu mentation is vague or leaves open areas of interpretation, it can become a Pandora’s box during claim assessment,” he says. The diagnosis, treatment rationale, investiga tion reports and discharge summary must clearly establish the medical facts and sup port the claims being made.

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To be sure, it is not easy for lay patients policyholders grappling with their own or their loved ones’ ill-health to decode medical terms or anticipate possible claim denials. But you can coordinate with the hospital to ensure that the documents are in order. “Ask the doctor to write a report that clearly explains the diagnosis. The doctor should explicitly state how the cur rent condition is medically distinct from any pre-existing or excluded conditions,” advises Arora. If you are filing a reim bursement claim, include all relevant lab work, X-rays, Magnetic Resonance Imaging (MRI) or pathology reports that confirm the diagnosis.

Keep an eye on medical records

Moreover, as a matter of practice, you ought to keep track of the notes in your medical files or those of your relatives who may be undergoing treatment. Focus on the section where the history of your health conditions, past surgeries or other procedures, and medications taken is mentioned.

“This is something that all policyholders must do. I have come across cases where claims have been rejected because of errors in hospital records. Even seemingly minor inaccuracies can trigger scrutiny; for in stance, describing a stroke that occurred 20 years ago as a condition the patient has had ‘for 20 years’ can impact how the claim is assessed,” says Sathe.

While it is not easy to remember policy details, particularly during medical crises, being aware of your policy’s exclusions can help reduce heartburn later.

“The treating doctor should clearly mention the diagnosis, the reason for treatment and, wherever relevant, that the condition is not related to the excluded ail ment,” says Gosar.

Apart from this, do not hesitate to ask your attending doctor or hospital staff questions, particularly when you notice details that do not match your medical history.

Patients and their relatives often do not carefully review discharge summaries due to unfamiliarity with complex medical jar gon. This could prove costly as typographi cal errors, incorrect pre-existing disease duration, mention of non-existent ailments, and so on can derail your otherwise payable health claim. In March this year, ET Wealth highlighted cases in which errors in hospital documentation led to claim rejections (https://bit.ly/3UlMPyh). For example, Delhi resident Manish Sharma had to face claim rejection due to an incorrect entry in his wife’s discharge summary.

He did not realise that ‘HTN’ mentioned in her health history referred to hypertension, which she never had. However, the insurer treated this as non-disclosure of pre-existing disease and denied the claim, leaving Sharma in a lurch.

In recent times, there have been multiple cases where consumer courts have passed orders in favour of policyholders for claims linked to ailments unrelated to excluded preexisting diseases, even if undisclosed.

“Even if some consumer courts have delivered the verdict in favour of policyholders, insurers have to abide by the policy terms and conditions while evaluating claims,” says Sathe.

This also holds true for conditions such as pregnancy, which is explicitly excluded from coverage under regular, non-maternity policies. “This becomes particularly im portant in policies that exclude certain preexisting conditions, specified ailments or their complications. For instance, if a policy excludes cancer and its complications, and the insured later develops another medical condition, the hospital records should clearly establish whether the new condition has any connection to the excluded disease,” explains Gosar. This can help prevent disputes or adverse interpretations during claim evaluation.

Know your recourse

Should your claim get rejected despite having taken all measures, you can still make your case again. “A strong letter from your treating physician is the key to getting such claims approved. Ask the doctor to write a letter explaining exactly why the treatment or medication is necessary. Ensure the letter directly addresses the insurer’s reason for denial, if applicable. The let ter should state the medical timeline to prove the condition arose separately from any exclusions,” says Arora.

If the claim is denied despite all efforts, you can still pursue the matter. To start with, submit a formal written appeal within the time limit set by your insurer. “Clearly state why the denial was incorrect based on your policy’s terms,” she adds. Approaching the company’s grievance redressal officer, followed by an escalation through IRDAI (Bima Bharosa portal), is the route you must take. You can also dial the insurance ombudsman if your complaint hits a wall. Finally, if all else fails, knock on the doors of consumer courts.