ICICI Lombard Insurance Claim Rejection: From ‘Ailment History Not Clear’ to ‘Pre-existing Condition Not Disclosed’: Why Did The Reason Change? A Faridabad family’s health insurance claim dispute with ICICI Lombard General Insurance has raised fresh questions over transparency in cashless health insurance pre-approvals, portability benefits and the way historical medical records are used while assessing present-day treatment claims. The case involves Mrs Sadhna Goel, 57, whose orthopaedic specialists advised having bilateral total knee replacement surgery after medical evaluation. Her family says they had maintained continuous health insurance coverage for more than four years, first with Star Health and later by porting the policy to ICICI Lombard in November 2025.
The current ICICI Lombard Elevate policy, according to documents reviewed, carries a Rs 1 crore family health cover. The family says the annual premium paid is above Rs 92,000.
But when the family sought cashless approval for Mrs Goel’s knee replacement surgery, the request was not approved. What makes the case significant is not just the rejection, but the sequence of reasons cited across communications.
This conflict arises at an important time for the family, according to Mr. Goel. As per Mr. Goel, Mrs. Goel’s Bilateral Total Knee Replacement surgery is planned for 29th June 2026. With the denial of the cashless pre-authorisation request, the family claims that they are currently in a rush to arrange Rs. 6 lakh to 7 lakh for this surgery despite having a health insurance policy of Rs. 1 crore.
Mr. Goel claims that despite numerous attempts, no help was provided through any customer support channels. “We are running out of time as the surgery is near, but we are being left all alone to arrange money despite us having an insurance policy. We keep trying for answers,” he said to NewsX.
In one communication, the insurer said it had not received enough information or documents to assess the claim. In another, the reason was recorded as “Ailment History – Not Clear.” In a later rejection letter, the reason changed to “Pre-Existing Condition Not Disclosed”, citing “NAFLD-GRADE-II FATTY LIVER” as the condition allegedly not declared when the policy was issued.
The family questions how an alleged fatty liver observation from 2022 can be used to deny or question a claim for knee replacement surgery in 2026.
“I was shocked and confused. As a policyholder, I could not understand how a knee replacement surgery recommended by orthopaedic specialists could be linked to an unrelated finding from a hospitalisation that occurred years earlier for fever and lung infection,” Sanjay Kumar Goel, the patient’s husband, told NewsX.
‘My Policy Was In Star Health For 4 Years’: The Portability Question
According to Sanjay Kumar Goel, the family had been covered under Star Health for four years before porting the policy to ICICI Lombard in November 2025.
“My policy was with Star Health for 4 years. In November, I ported it to ICICI Lombard,” he said.
He added that the family understood the continuity benefit to mean that waiting periods would be adjusted against the period already served under the previous policy.
“According to the rule of IRDAI, portability is applicable after it has been ported. That is also mentioned in their policy. It is mentioned in the policy that your policy will be continuously managed from 4th or 5th November 2021. And after 3 years, the pre-existing disease is also covered,” he said.
The policy wording shared by the family says that if an insured person is continuously covered without any break as defined under applicable portability norms stipulated by IRDAI, then the waiting period would be reduced to the extent of prior coverage.
This is a key part of the dispute. The family argues that since the policy had continuity from 2021 and was ported to ICICI Lombard with continuity benefits, the insurer should clearly explain whether any waiting period, exclusion or non-disclosure clause still applies to the knee replacement claim.
‘This Was Not A Pre-Diagnosis’: What Hospital Records Show
The file of Mrs Sadhna Goel at the Amrita Institute of Medical Sciences & Research Center, Faridabad, noted her date of consultation as 23/05/2026.
The Amrita Hospital surgical OPD record mentions bilateral knee pain and says the pain had recently increased and was affecting daily activities. Under advice, the document records, “Patient needs bilateral total knee replacement – robotic assisted.”
The same document advises blood tests, a chest X-ray, an ECG, cardiology clearance for surgery and a pre-anaesthetic check-up.
Another Amrita Hospital document titled “Reply to TPA Query” states that the patient visited the OPD on May 23, 2026, with a history of bilateral knee pain and complained of pain for the last 2–3 months. It further states that assessment and X-rays showed advanced osteoarthritis in both knees and that she had been advised to have a bilateral total knee replacement, robot-assisted.
Goel said the family had not been dealing with a long-known knee condition.
“In my wife’s case, she did not have a knee problem earlier. There was a little pain in the hand. She used to take Combiflam to relieve the pain. Now, after a month or two, there was more of a problem. So we took her to Amrita Hospital. Amrita Hospital said that her knees are damaged. She will have to undergo knee surgery. This was not a pre-diagnosis. It was a sudden case,” he said.
First Rejection: ‘Enough Information/Documents’ Not Received
The first cashless approval for the upcoming denial of the knee surgery reviewed by NewsX is dated May 23, 2026.
The letter says the pre-authorisation claim request dated May 23, 2026, was an insurance claim pre-approval that was denied because the insurer had not received enough information or documents to assess it according to the policy terms.
The letter states, “We cannot process your claim, as we haven’t received enough information/documents to assess it as per policy terms. If you share additional details or documents, we will be happy to review it once again.”
At this stage, fatty liver was not mentioned in the rejection communication. It did not cite NAFLD. It stated that the claim was not being rejected due to a pre-existing condition.
For the family, this first reason suggested that the claim could be reconsidered if further documents were provided.
Query Letters: ‘Past History With Duration’ And Combiflam
Subsequent query letters from ICICI Lombard sought more information from the hospital.
A query dated June 6, 2026, asked for the “past history of osteoarthritis knee with the duration for the same”. It also asked for a treating medical practitioner’s letter stating the medical history of co-morbidities, if any, including hypertension, diabetes, COPD, asthma, heart ailment or any other major illness.
Another query dated June 8, 2026, asked for “all past OPD consultation paper investigation reports regarding diagnosis prior to this hospitalisation date 23-05-2026 and OPD consultation paper advised tab Combiflam for further process of cashless”.
Both letters included a note that if the query reply was not received in two days, it would result in rejection of the case.
The family says documents and clarifications were submitted, including hospital records.
“Amrita Hospital submitted the documents for the operation under their cashless scheme. They rejected it by saying that the history is not clear. Meanwhile, we also showed it in BL Kapoor. BL Kapoor also diagnosed it. And when BL Kapoor filed it, they put Amrita Hospital’s documents as history. But they also said that the history is not clear,” Goel said.
Second Reason: ‘Ailment History – Not Clear’
Another ICICI Lombard denial letter, dated June 8, 2026, under claim number 126006443900, states the reason as “Ailment History – Not Clear.”
The letter states: “We cannot process your cashless claim request as we have not received complete details on how long you have had the said ailment. You may still submit a claim request through the reimbursement process with this information.”
This communication again refers to “Condition Precedent to Admission of Liability” under the general terms and conditions.
This is where the family sees inconsistency. The Amrita Hospital’s reply to the TPA query stated that the patient had complained of pain for the last 2-3 months. The family says BLK-Max also evaluated the patient and advised bilateral total knee replacement.
A handwritten BLK-Max prescription shared by the family records osteoarthritis of both knees and advice for bilateral TKR. It is signed and stamped by Dr Bhushan Nariani, Chairman and Head of Joint Diseases and Joint Replacement, BLK-Max Super Speciality Hospital.
Then Came ‘NAFLD-GRADE-II FATTY LIVER’
A later rejection communication dated June 8, 2026, cites a different reason: “Pre-Existing Condition Not Disclosed.”
The letter states: “The patient was diagnosed with a pre-existing condition: NAFLD-GRADE-II FATTY LIVER, which was not declared when the policy was issued; hence, the claim was rejected.”
The letter refers to “Disclosure of Information” under the policy wordings.
This is the most disputed part of the case.
Goel says the fatty liver reference appears to have been picked from an April 2022 hospitalisation record, when his wife was admitted for fever, weakness, dehydration and lung-related infection. He says the primary treatment at that time was not for any liver disease.
“After that, in 2022, my wife was admitted to Medanta Hospital. At that time, the fever was very high. Before Medanta, she had been admitted to Asian Hospital. They were saying that she has a liver problem. I did not understand there. I discharged her from there in LAMA and took her to Medanta. When I took her to Medanta, they diagnosed her with pneumonia and treated her for it,” he said.
He added that the fatty liver mention was not the basis of the treatment.
“When I discharged her in LAMA, it was written there that she has fatty liver. Now, they picked up the report from 2022 and said it was a case of fatty liver and that you did not disclose it. But there was no treatment for the liver. Nothing happened,” he said.
‘Knee Surgery Is Completely Different And Fatty Liver Is Completely Different’
The family’s central question is simple: what is the medical connection between a fatty liver observation and a knee replacement surgery claim?
In a written response to NewsX, he added: “As an ordinary policyholder, I could not understand how a medically necessary knee replacement surgery could be questioned on the basis of an alleged liver-related observation made years earlier, particularly when no clear medical link was explained to us.”
He said if the insurer believes there is a medical connection, it should clearly explain it.
“If an insurer believes there is a medical connection, it should clearly explain the basis of that conclusion and identify the specific policy provision being relied upon. As a customer, I expected transparency and a reasoned decision rather than uncertainty and changing explanations,” he said.
It is important to note that NewsX is not making a medical determination on whether any past condition was material to the policy. That is for medical and insurance experts to assess. However, the documents reviewed raise a legitimate transparency question: did ICICI Lombard explain why an alleged fatty liver condition was relevant to a claim for bilateral knee replacement surgery?
The rejection letter cites non-disclosure of NAFLD Grade II fatty liver but does not explain the medical link between this alleged condition and the knee surgery for which cashless approval was sought.
‘That Claim Was Approved Then’: The 2022 Hospitalisation Question
The family also raises another point. According to Goel, the April 2022 hospitalisation records, which allegedly contained the mention of fatty liver, were already part of an insurance claim that was processed at the time.
“An important fact that should not be overlooked is that we processed the April 2022 hospitalisation at Asian Hospital under our health insurance policy with Star Health & Allied Insurance Company. At that time, the policy had been in force for only a few months, having commenced in November 2021. The hospital records from April 2022 contained the same observations that are now being referred to by the insurer, including the mention of Grade II fatty liver. Despite these findings, the insurer approved and settled the claim for that hospitalisation at that time,” he said.
This claim needs confirmation from the insurer and previous policy records, but if correct, it raises a serious question about consistency.
“If the insurer considered the findings recorded in the 2022 hospitalisation significant enough to affect future coverage, why was the claim approved at that time? Why was no issue raised regarding alleged non-disclosure, misrepresentation, or material medical history at that stage?” Goel asked.
The family says the policy continued for years after that and was later ported to ICICI Lombard with continuity benefits.
“For nearly four years thereafter, the policy continued uninterrupted and was subsequently ported to ICICI Lombard, with continuity benefits being accepted. Today, when a completely unrelated total knee replacement surgery is being sought, the same historical medical records are being scrutinised in a manner that appears inconsistent with the insurer’s earlier conduct,” Goel said.
‘Surgery is on June 29 but Family Has to Arrange Funds’
Despite the claim issue being unresolved at present, the foremost concern of the family now is arranging funds for the upcoming surgery.
Mr. Goel informed that the bilateral total knee replacement surgery of Mrs. Goel was due on June 29, 2026. The cost of the treatment has been estimated around Rs 6-7 lakhs.
As per the family, the decision to deny cashless pre-authorisation has put them in dire straits due to the fact that their surgery date was nearing and they had to make other arrangements in a short span of time.
“Actually, we got this health insurance policy in order to avoid such an arrangement during emergencies. However, with the approach of the surgery date, we are making other arrangements for the surgery as well as making the claim,” Goel added.
It may be noted here that Mr. Goel had made several attempts to get clarifications on their claim, yet he failed in getting satisfactory responses.
“In spite of making various efforts in connecting with relevant people for our assistance and clarifications, yet we do not have any satisfactory response till now,” Goel informed.
‘Rs 1 Crore Cover, Rs 92,000 Premium’: Family Says It Expected Support
The family says it had a Rs 1 crore family floater policy and paid an annual premium exceeding Rs 92,000.
“The current policy provides a health cover of Rs 1 crore for my family, and the annual premium paid for the policy exceeds Rs 92,000. Like millions of Indian families, we paid these premiums with the belief that health insurance would provide support during a genuine medical emergency,” Goel said.
He said the estimated hospital expenditure for the knee replacement surgery is estimated to be around Rs 6 lakh to Rs 7 lakh.
“The estimated hospital expenditure for the total knee replacement surgery was approximately Rs 6 to 7 lakh, depending upon the final package and post-operative treatment requirements. We sought cashless approval under our Rs 1 crore family floater health insurance policy,” he said.
He said the family was forced to look at personal savings and alternative arrangements after the cashless claim approval did not go through.
“Like many middle-class families facing a medical emergency, we were forced to explore personal savings and alternative arrangements while simultaneously pursuing the claim dispute. This created tremendous financial stress because health insurance is purchased precisely to avoid such situations,” he said.
‘The Reasons Appeared To Vary’: Policyholder Questions Transparency
The family says its concern is not just about money but about how claim decisions are communicated.
“What has caused significant concern is that different communications issued by the insurer cited different reasons instead of clearly identifying a specific policy exclusion or contractual provision that would make the claim inadmissible,” Goel said.
He added that no communication clearly identified what exactly made the claim inadmissible.
“The most concerning aspect is that no communication provided to us clearly identified any specific exclusion clause applicable to the claim, any waiting-period clause that would bar the claim, any proven non-disclosure relating to the knee condition, or any medical evidence establishing that the claim was outside policy coverage,” he said.
In his response to NewsX, he said: “My concern is not only about my family’s claim. It is about transparency and fairness. If a claim is being denied, policyholders deserve a clear explanation, supported by specific policy clauses and medical evidence.”
The family says the sequence of communications created confusion because different reasons were given at different stages of the assessment process. While insurers may seek additional documents and arrive at a final conclusion after review, the family maintains that the final rejection did not clearly explain why the alleged fatty liver observation was relevant to a knee replacement claim.
LinkedIn Post: ‘Health Insurance Should Provide Peace Of Mind’
Goel also shared his ordeal on LinkedIn, saying he was “deeply disappointed” with ICICI Lombard and PolicyBazaar.
“My wife requires a Total Knee Replacement (TKR) due to severe knee degeneration. However, the cashless authorization has been denied by [ICICI Lombard](https://lnkd.in/gyJHaHEB), citing a completely unrelated medical record from years ago,” he wrote.
He said the rejection appeared to be based on an old fatty liver diagnosis from 2022.
“More importantly, there is absolutely no medical connection between an alleged liver condition and advanced knee osteoarthritis requiring knee replacement surgery,” he wrote.
He also expressed disappointment with PolicyBazaar, which he said sold him the policy.
“When customers buy insurance through a platform, they expect guidance, support, and effective representation during difficult claim situations. Unfortunately, I have not experienced the level of assistance I expected,” he wrote.
His post ended with a line that captures the larger consumer concern in this case: “Health insurance should provide peace of mind, not additional stress during a medical crisis.”
What The Documents Establish — And What Still Needs Answers
Based on documents reviewed by NewsX, the following facts are clear:
Mrs Sadhna Goel was advised a bilateral total knee replacement by Amrita Hospital after evaluation for knee pain and advanced osteoarthritis. BLK-Max records also advised bilateral TKR. ICICI Lombard communications first sought additional information on the ailment history and co-morbidities. A rejection letter cited insufficient documents. Another cited “Ailment History – Not Clear”. A later rejection cited “Pre-Existing Condition Not Disclosed” and named NAFLD Grade II Fatty Liver.
What remains unclear and requires a response from ICICI Lombard is whether the alleged fatty liver condition was considered material at the time of policy issuance, whether it was specifically sought and not disclosed in the proposal form, how portability benefits were applied in this case, and what medical reasoning was relied upon while assessing the knee replacement claim.
The insurer also needs to clarify whether the 2022 hospitalisation records formed part of the underwriting or portability assessment process and whether the earlier hospitalisation claim was settled as alleged by the family.
ICICI Lombard Insurance Company Is Yet To Respond
NewsX has sought ICICI Lombard’s response regarding the claim rejection, the varying reasons cited in different communications, the applicability of portability benefits, and the policyholder’s allegations regarding the handling of the claim. The company had not responded at the time of publication. This report will be updated once we receive a response.
Why This Case Matters Beyond One Family
Health insurance disputes often turn on technical clauses, medical records, disclosures and waiting periods. Insurers are entitled to verify claims and seek documents before authorising cashless treatment. They are also entitled to reject claims if there is clear evidence of non-disclosure, exclusion or violation of policy terms.
But policyholders are equally entitled to clear, consistent and reasoned communication. When different explanations emerge at different stages of claim assessment, it can create confusion and undermine confidence in the decision-making process.
This case also raises questions about how portability benefits are applied when policyholders move between insurers after maintaining continuous coverage for several years.
For Goel, the issue is about accountability.
“Customers pay premiums for years in good faith. When a genuine medical emergency occurs, claim decisions should be transparent, consistent, and based on clearly stated policy terms rather than changing explanations,” he said.
His advice to all other policyholders is straightforward: “Make sure that everything about you, from your medical records, proposals, renewals, and communications with the insurance company, is preserved safely. Take time to study your insurance policy well and be ready to question any claim if you really think the insurer is wrong.”
With the surgery scheduled for June 29, the family says every passing day increases both the financial and emotional pressure on them.
As of now, the family continues to seek reconsideration of the claim. ICICI Lombard’s response is awaited.
Priyanka Roshan is a business writer and assistant editor at the NewsX website who tracks everything from stock market swings and corporate earnings to personal finance trends and policy shifts. Known for turning fast-moving business developments into sharp, reader-friendly stories, she combines speed, accuracy, and a data-driven approach to break down complex financial news for everyday audiences.
With over 9.5 years of newsroom experience, Priyanka has worked with leading media organisations, including Moneycontrol, Times Now, and Ping Digital, covering diverse beats such as business, politics, technology, auto, travel, sports, and the world. From live breaking news desks to SEO-led digital storytelling, she specialises in creating engaging content that keeps readers informed without overwhelming them.
