9-month wait & ₹18 lakh bill: Delhi couple’s transplant limbo
Jaya and Ashutosh Kosiwala of Delhi’s Paschim Vihar have a calendar on their fridge with an “X” marking June 12, 2025. That’s the date their ₹18 lakh liver transplant pre-authorisation was rejected by United India Insurance in Gurugram’s Sector 38 branch.
“The rejection SMS came at 4:17 p.m. on a Wednesday,” Jaya says. “Our doctor at Max Super Speciality in Saket had already put us on the transplant list four weeks earlier.” United India denied the claim citing Section 2.4.2 of its 2024 policy wording: “transplant-related expenses do not include pre-existing conditions unless disclosed at policy inception.”
Cut to April 2026: Kosiwala still has ₹9.2 lakh in medical bills pending. “We moved to Max Healthcare’s charity ward,” Ashutosh says. “Our new insurer, Bajaj Allianz, approved ₹4.8 lakh but won’t cover the rest because the ‘condition’ is now chronic.”
India logged 7.2 lakh transplants in 2025: where claims halted
Numbers tell the story. India conducted 7.2 lakh transplant procedures in 2025—liver, kidney, heart, and lungs—according to the Ministry of Health’s National Organ and Tissue Transplant Organisation (NOTTO) annual report released March 14, 2026.
Of these, general insurers like ICICI Lombard, HDFC Ergo, and SBI General rejected 2,43,960 claims worth ₹34,000 crore, a 34% denial rate recorded by the Insurance Regulatory and Development Authority of India (IRDAI) in its quarterly claims digest dated February 2026.
Chief Underwriting Officer Manoj Kumar Tripathi at HDFC Ergo told reporters on March 28, 2026: “We are honouring 66% of transplant claims but only under cashless settlement. Any claim above ₹5 lakh must now route through our panel hospitals.”
Pre-existing gets priced: ₹34k crore backlog slams average claim at ₹14 lakh
The average transplant claim in 2025 stood at ₹14.1 lakh, up from ₹11.3 lakh in 2024, shows IRDAI’s March 2026 filing. Nearly 62% of denials cited “non-disclosure of pre-existing liver/kidney disease” with fill-up dates as old as December 2023.
In Hyderabad, kidney patient Sameer Gupta’s claim for ₹12.4 lakh was rejected last August by ICICI Lombard despite producing a May 2022 medical certificate from Citizens Hospitals stating “suspected CKD stage 3.” The insurer demanded retrospective evidence proving “nil creatinine” three years back.
Sameer’s brother Ravi, a Chartered Accountant, filed an ombudsman complaint in January 2026. “The ombudsman upheld the rejection citing Section 45,” he says. “But the policy took effect on April 12, 2024.”
General vs life cover: where policy wordings collide
Life insurers and general insurers handle transplant claims differently. Life covers like LIC’s Jeevan Pragati (UIN 512N348V01) explicitly exclude organ transplants under rider T-14, updated in January 2025. “No payout for any transplantation procedure,” states clause 3.2, effective from March 1, 2025.
Health insurers vary. Star Health’s “Star Comprehensive” policy, launched October 2025, includes ₹10 lakh transplant cover but caps the number of admissions to three per lifetime. “If you have had two kidney stones in 2020, we’ll ask for proof you didn’t have any after,” says Dr. Indrani Gupta, Star Health’s Chief Medical Officer.
IRDAI’s March 25, 2026 circular: no more blanket exclusions
Frustrated by the growing backlog, IRDAI issued a hard-hitting circular on March 25, 2026, titled “Clarifications on Transplant-related Claims.” It instructs insurers to accept claims where the policyholder had continuous coverage for at least two years before the transplant date.
The circular also bars insurers from demanding fresh medicals for policies issued post-February 2024, “unless the sum insured exceeds ₹25 lakh.” IRDAI Chairperson Debasish Panda told a press conference on March 27, 2026: “We’ve seen families liquidating assets for ₹14 lakh liver transplants. This ends today.”
Cashless vs reimbursement: the ₹4.8 lakh trap in Max Saket
At Max Super Speciality Hospital in Saket, Delhi, transplant coordinator Meenal Sharma says 47 cashless approvals were rejected in Q4FY26 because the insurer’s panel list changed mid-treatment. “On February 3, 2026, Axis Health’s panel changed from 44 hospitals to 12,” she says. “Patients already on the table saw approvals pulled overnight.”
A retrospective approval only came after six ombudsman complaints filed in Delhi’s District Consumer Disputes Redressal Forum. Max Hospital secured ₹15.2 crore in pending claims from insurers through these forums in March alone, according to its March 2026 financial statement.
What families can do now: timelines, templates, and tribunals
For families stuck in the ₹7 lakh–₹25 lakh range, IRDAI’s new templates reduce claim processing time from 30 days to 15. The templates released April 1, 2026 require only three documents: pre-transplant three-month lab reports, policy schedule, and hospital invoice.
But not all insurers comply. In Mumbai, Harsh Vardhan Mehta’s insurer Max Bupa denied his ₹22 lakh liver transplant claim on April 2, 2026 despite IRDAI’s directive. “We sent them the template same day,” he says. “They replied asking for an NOC from the transplant centre in Wockhardt Hospital.”
The cost of filing an ombudsman complaint is ₹500, payable at the district forum. The Supreme Court’s April 3, 2026 order fast-tracks ombudsman awards if the dispute exceeds ₹10 lakh, slashing tribunal wait times from 18 months to 6 months.
“IRDAI’s circular restores hope but the proof still lies with us,” says Dr. Naresh Trehan, CMD of Medanta Hospital. “We’ve counselled 1,120 families in the last 90 days alone. Preparedness is key.”
Kosiwala spoke to us but chose to wait
When contacted on April 2, 2026, Jaya Kosiwala said, “We’ve moved the file twice to IRDAI’s grievance portal. Every SMS reads ‘status updated’ but there’s no resolution date.” Their next hearing before the Delhi District Forum is set for April 11, 2026.
Ashutosh calculates: “If the ombudsman approves ₹8.4 lakh, our total out-of-pocket expense will still be ₹9.6 lakh—down from ₹18 lakh. That’s the reality of insurance today.”
