ICICI Lombard Rejects Emergency Health Insurance Claim Over Diagnosis Dispute, Matter Escalated to IRDAI

A health insurance claim filed with ICICI Lombard General Insurance Company Limited has been rejected following an emergency, life-saving surgery, raising serious questions about the interpretation of medical diagnoses and waiting-period clauses in health insurance policies.

The case relates to the hospitalization of a 50-year-old patient in December 2025 for gangrenous cholecystitis with pericholecystic abscess, a severe and potentially fatal infection of the gallbladder. According to hospital records, the patient underwent emergency laparoscopic surgery due to acute infection and tissue gangrene.

As per the final discharge summary and operative notes, no gallstones were found intra-operatively, and the surgery was necessitated by infection rather than gallstone disease.

Despite submission of complete medical records, ICICI Lombard rejected the reimbursement claim, citing a two-year waiting period applicable to cholelithiasis (gallstone disease) under the policy’s specified disease exclusion. The rejection letter stated that the claim was not payable under the waiting period clause.

However, the policyholder has disputed this decision, stating that cholelithiasis was neither the final diagnosis nor the reason for surgery. Medical documentation describes the condition as gangrenous and acalculous cholecystitis, which is clinically distinct from gallstone-related disease.

A review of the policy wording indicates that gangrenous cholecystitis, acalculous cholecystitis, and pericholecystic abscess are not explicitly listed under specified diseases requiring a two-year waiting period. The policyholder has further stated that ICICI Lombard has not provided any specific policy clause or page reference explaining how an emergency infection was equated with cholelithiasis.

Additional concerns have been raised regarding claims handling procedures. Records show that ICICI Lombard had informed the policyholder that the claim was under verification with a stated turnaround time, yet a rejection was issued before the completion of the verification period.

The matter has now been escalated to the Insurance Regulatory and Development Authority of India (IRDAI) through the Bima Bharosa grievance portal, where it is currently under regulatory review.

The family has also raised concerns regarding patient privacy, alleging that during hospitalization, an individual claiming to be associated with claim verification entered the hospital ward without prior consent. The family states that documentary and photographic evidence has been retained.

Consumer rights experts note that disputes of this nature underscore a broader issue in health insurance claims, particularly in emergency medical cases where initial imaging findings may differ from final operative diagnoses. Established insurance principles recognize that final diagnosis and surgical findings should take precedence when determining claim admissibility.

The policyholder has stated that the family is seeking a fair, clause-based reassessment of the claim by ICICI Lombard, strictly in accordance with medical evidence and policy wording, and is awaiting further directions from the insurance regulator.