Ombudsman rules, but are health insurers playing fair?

How to enforce ombudsman awards, challenge cancellations, ensure uninterrupted coverage

- Aprajita Sharma

When 60-year-old Lakhwinder S. Lamba finally got his health insurer to pay for his heart surgery after a yearlong battle, he thought the worst was over.

Then came another shock—his insurer refused to renew his policy altogether.

“I had undergone a precautionary heart scan in 2006. Nothing significant came up in the report and no treatment ever happened. I happened to mention it to the treating doctor when I got hos-pitalised in May 2023 for an open heart surgery. The insurer rejected my claim [for the surgery] and cancelled the policy saying that I hid a preexisting disease. But I had no heart ailment when I bought the policy in 2015,” said Lamba, who retired from an IT hardware and software sales business in New Delhi.

Lambv’s insurer reimbursed him for the surgery after the insurance ombudsman ruled in his favour, but cancelled his policy. “I had received my claim in April 2024. I've been chasing them to renew my policy since then, but no luck so far,” he said.

Health insurers cannot deny a claim on grounds of nondisclosure of preexisting diseases if a policy has run continuously for at least five years, except in cases of fraud or deliberate misrepresentation. But Lamba, who says he didn’t have any heart-related ailments when he took the policy in 2015, isn’t alone in such run-ins with health insurers. "We have been receiving a lot of such cases where despite claims (being approved) by the ombudsman, can-celled policies don’t get reinstated,” said Shilpa Arora, co-founder and chief operating officer of Insurance Sama-dhan, an insurance grievance redressal platform.

Meerut-based Azhar Ahmed, 33, had a similar experience. He bought a health insurance policy for his family in 2022 and was hospitalised in 2024 for kidney stones.