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Health Insurance Claim of ₹8 Lakh Settled for a Critical Illness Patient
How WizBiz helped a Delhi professor get her ₹8.2 lakh breast cancer treatment claim approved after the insurance company rejected it citing pre-existing conditions.
Health Insurance Claim Settlement | Critical Illness | Case Study | WizBiz
Insurance, Health Insurance, Claim Settlement, Critical Illness, IRDAI, Delhi, Cancer Treatment
WizBiz Team
Challenge
Dr. Ananya Kapoor, 45, a university professor in Delhi, was diagnosed with breast cancer in early 2025. She had a corporate health insurance policy of ₹10 lakh from her employer and a personal top-up plan of ₹15 lakh. Her treatment at a leading oncology hospital in Gurugram required surgery, chemotherapy, and radiation, totalling ₹8.2 lakh. When she filed her claim, the insurance company rejected it citing a 'pre-existing condition' clause, claiming her symptoms dated back to before the policy inception. She was devastated — facing a critical illness and a ₹8.2 lakh bill that insurance wouldn't cover.
Solution
Our insurance claims team reviewed Dr. Kapoor's policy documents, medical reports, and the insurance company's rejection letter. We identified that the rejection was based on an incorrect interpretation of the policy's 'pre-existing condition' clause. We: (1) Collected medical records dating back 5 years to prove she had no history of cancer symptoms; (2) Drafted a detailed appeal letter citing IRDAI guidelines on pre-existing conditions; (3) Filed a formal complaint with the Insurance Ombudsman; (4) Coordinated with the hospital's insurance desk for cashless processing; (5) Followed up relentlessly with the insurance company's grievance redressal team. We also guided her on filing claims under both her corporate and top-up policies to maximise coverage.
RESULTS
After 8 weeks of persistent follow-up, the insurance company reversed its decision and settled the full claim of ₹8.2 lakh via cashless processing. An additional ₹1.8 lakh from the top-up policy was approved for follow-up treatment. Dr. Kapoor paid zero out-of-pocket for her primary treatment. She is now in remission and continues her follow-up treatment covered by insurance. We also helped her get a portability certificate to switch to a better policy without waiting periods.
Key Metrics
Claim Amount: ₹8.2 Lakh
Top-Up Claim: ₹1.8 Lakh
Total Covered: ₹10 Lakh
Time to Resolve: 8 Weeks
Out-of-Pocket: ₹0
Policy Type: Corporate + Top-Up
Testimonial
Being told your insurance won't cover cancer treatment while you're fighting the disease is devastating. WizBiz fought for me when I couldn't fight for myself. They got my claim approved and I could focus on my treatment and recovery. I'll be forever grateful to their team.
