When Fameel Mohamad injured his knee playing football in January last year, he didn't expect the real struggle would begin off the field. Doctors diagnosed a tear in his knee and said he will need surgery. That part went as expected, what didn't was the insurance claim settlement ordeal which took over a year to resolve.
The problem? Despite holding an active health insurance policy with a reputed insurer, his request for cashless treatment was denied. The company said his policy had not completed four years, something he was not told when he bought the policy. At the core of it, this issue is similar to many other claim stories wherein people face rejection because of 'undisclosed Pre-existing diseases' at the time of policy purchase. Fameel's case, however, was different.
What was the case?
On January 23, 2024, Fameel suffered a medial meniscus tear in his knee while playing football in Kondotty. After three reputed doctors confirmed the need for surgery, he was admitted to Baby Memorial Hospital, Kozhikode, and underwent arthroscopic medial meniscal balancing on February 2, 2024.
Like many other policyholders, he believed his health insurance policy will offer the financial support as promised but when he sought cashless treatment under his active plan, the company rejected his claim citing an unmet waiting period.
The real shock came later when the insurer flatly refused reimbursement as well, calling the knee injury a "pre-existing disease" (PED).
This classification baffled Fameel. "I had never been diagnosed or treated for any knee issue before. How could this be called pre-existing?" he wrote in a detailed LinkedIn post that has since gained traction.
The Path to Justice
The rejection by his insurer was rooted in the assumption that a hospital token issued back in 2021 for an orthopaedic consultation hinted towards a prior knowledge or treatment of the same knee issue. However, there were no prescriptions or diagnosis to back this assumption, only a record of a doctor visit.
Despite providing hospital case sheets and multiple doctor confirmations disproving any prior condition, the insurer maintained its stance.
The ordeal did not stop there. Fameel sent an email to his insurer's grievance redressal team, chased documents from the hospital, and made more than 20 follow-ups.
All of it took a toll on him emotionally, mentally, and physically, especially when paired with the recovery from knee surgery. "This felt like an attempt to portray me as dishonest - a deliberate misjudgment of facts, not just a denial of claim," he wrote.
After seeing no resolution, he finally complained with the Insurance Ombudsman and the hearing took place online in April 2025.
The insurer alleged that he had consulted an orthopaedic specialist in 2021 and Fameel acknowledged that it was possible he had visited a hospital then, maybe for a general concern, but certainly not for a knee injury. And since there was no actual record to back up the insurer's claim, the Insurance Ombudsman ultimately sided with Fameel.
In May, the office passed an order asking the insurer to pay Rs 1,20,806 within 30 days, and the claim amount arrived in his account a week later.
The entire ordeal left Fameel feeling drained. "At times, I felt like giving up," he said in his post. "But I had the support of a good friend, and that helped."
What are the rules related to PEDs?
The case brings up a common, and often poorly understood, issue in health insurance: what counts as a pre-existing disease (PED).
In insurance terms, a PED refers to any condition you have had before the start of your policy. This could mean an official diagnosis and also some ongoing symptoms, or treatment that suggests you might have known about a problem before taking the policy.
The rules say that if you knowingly omit details about your medical history when signing up, the insurer can deny claims related to those conditions. But insurers also need to have concrete proof. For instance, a vague past consultation, without a prescription or diagnosis, should not be enough.
Recent changes by the Insurance Regulatory and Development Authority of India (Irdai) have helped somewhat. The waiting period for PED coverage is now three years instead of four. This means that, if you have been renewing your policy without breaks, most declared pre-existing conditions are covered after three years.
There are also PED reduction riders, such as some add-ons that let you shorten the waiting period for specific conditions like diabetes or hypertension, sometimes down to one year or even less. These usually cost more, but they offer some relief to affected patients.
What is absolutely critical, though, is necessary 'disclosure'. If you have been treated for something, or even seen a doctor for recurring symptoms, it is best to mention it when buying a policy as it will prevent disputes later.
