Claim rejected for a congenital condition? Read your policy wording, and check the waiting period.
Policy wordings treat internal and external congenital anomalies differently, and New India Assurance's Arogya Sanjeevani policy puts internal ones under a 24-month waiting period rather than excluding them. Here is how to test the rejection against your own policy.
Reviewed by the BimaHaq Insurance Grievance Desk — BimaHaq's in-house insurance-grievance team — specialists in IRDAI grievance redressal, the Insurance Ombudsman process, and policyholder rights in India. · Last reviewed 2026-10-26
Start from your own policy wording, not from older IRDAI instruments. A 2019 IRDAI guideline once listed internal congenital diseases among the exclusions a health policy could not carry, and a 12 October 2022 circular required cover for newborns' internal congenital defects from day one — but IRDAI's 2024 Master Circular on Health Insurance Business superseded the 2022 circular and the 2020 standardisation master circular, and neither that Master Circular nor IRDAI's 2024 Insurance Products Regulations restates the 2019 list. So the question is what your policy says. Wordings define an internal congenital anomaly (one not in the visible and accessible parts of the body) separately from an external one, and some cover internal ones after a waiting period: New India Assurance's Arogya Sanjeevani wording, for example, lists 'Internal Congenital Anomalies' under its 24-month specific waiting period. If your policy treats the condition that way and the waiting period has run on continuous cover, a rejection on that ground can be challenged. If an ambiguous clause remains in play, it is read against the insurer that drafted it.
Why insurers reject on this ground
The insurer says the condition treated existed from birth and falls under the policy's congenital-anomaly exclusion — a ground that surfaces in claims for cardiac septal defects, hernias attributed to congenital weakness, and similar diagnoses, sometimes years after the policy began.
When you can challenge it
First establish what your policy actually says about congenital conditions: whether it excludes them, puts them under a waiting period, or treats internal and external anomalies differently. Do not rest the challenge on the 2019 exclusion guidelines or the 12 October 2022 newborn circular alone: the 2024 Health Master Circular superseded the 2022 circular and the 2020 standardisation master circular, so the insurer will dispute that either binds it today. Lead with your own wording. If your wording puts internal congenital anomalies under a waiting period, count your continuous cover, including credit carried over on porting; once that period has run, the condition is covered on the policy's own terms. Then test the label itself — the insurer must establish medically that the condition is congenital rather than acquired, and whether it is internal or external, and a treating doctor's opinion can contest a TPA's assumption. Under the 2024 Health Master Circular no claim may be repudiated without the insurer's Claims Review Committee, and the rejection must give details with reference to the specific policy terms. Finally, if the rejection is dressed as non-disclosure, remember that you cannot conceal a condition you never knew you had — an internal congenital condition that first surfaced after the policy began was not a known fact you failed to disclose.
How to fight this rejection
- 1
Get the clause quoted verbatim, and find the waiting period
Obtain the rejection letter citing the exact clause — an exclusion, a waiting period or a definition. Then read your policy wording for how it treats congenital anomalies: some wordings put internal ones under a specific waiting period (New India Assurance's Arogya Sanjeevani lists them under its 24-month waiting period) rather than excluding them. If yours does, the question is whether that period has run on your continuous cover.
- 2
Establish the condition's medical character
Ask your treating doctor whether the condition is truly congenital or could be acquired, whether it is internal or external in the policy's sense, and when it first became known or symptomatic.
- 3
Answer any concealment angle head-on
If the insurer alleges non-disclosure, set out in writing when you first learned of the condition — a diagnosis made after the policy started, of a condition you had no symptoms of, is not concealment.
- 4
Raise a written grievance with the insurer's GRO
Send a dated grievance to the insurer's Grievance Redressal Officer setting out why the rejection is wrong. The insurer must acknowledge it immediately and resolve it within 14 days.
- 5
Optionally, complain to IRDAI on Bima Bharosa
If it isn't resolved in time or the reply is unsatisfactory, you can also register the complaint on IRDAI's Bima Bharosa portal. It is optional: the Insurance Ombudsman does not require it.
- 6
Take it to the Insurance Ombudsman
Free, and the award binds the insurer. The Ombudsman can award up to ₹50 lakh — a cap on the award rather than the claim. File within one year of receiving the insurer's rejection — or, if it never replied, within one year of one month after you sent your representation.
Common questions
Are congenital diseases covered by health insurance in India?
It depends on your policy. Wordings distinguish internal congenital anomalies (not in the visible and accessible parts of the body) from external ones and can treat them differently — New India Assurance's Arogya Sanjeevani wording, for example, covers internal congenital anomalies after a 24-month specific waiting period. Older material cites IRDAI's 2019 exclusion guidelines and its 12 October 2022 newborn circular as barring internal-congenital exclusions, but the 2024 Health Master Circular superseded the 2022 circular and the 2020 standardisation master circular, so rely on the wording of your own policy rather than on them.
I didn't know I had a congenital condition. Can the insurer call it non-disclosure?
Concealment requires knowledge. If the condition was internal, symptomless, and first diagnosed after the policy began, you had nothing to disclose — say so in your grievance with the medical records showing the date of first diagnosis.
What is the difference between internal and external congenital anomalies?
In health-insurance wording, external congenital anomalies are those in the visible and accessible parts of the body, while internal anomalies are those that are not — such as a heart septal defect. The distinction matters because a policy can treat the two kinds differently — for example by putting internal anomalies under a waiting period — so check which kind your condition is and what your own wording says about it.
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This guide is general information about the insurance-grievance process in India, not legal advice, and figures (timelines, monetary limits, jurisdiction) can change — verify against the official sources linked above before you rely on them.