Despite growth in healthcare premiums, insurers have seen higher levels of Covid claims in the first three months of the financial year due to the second wave of the pandemic.
Kavita, a 34-year-old resident of Pune, recently underwent myotomy laparoscopy. After her operation, she realized the importance of health insurance and applied to various insurers. However, her applications were rejected. The insurers told her they would not accept a person who has undergone major surgery.
Have you been refused a policy on similar grounds?
What can you do if you find yourself in a similar situation? Let’s understand the details.
Why do insurers deny claims after surgery?
“The insurance companies make a decision to provide cover based on the risk assessment of an individual’s medical condition,” says Siddharth Singhal, head of health insurance at Policybazaar.com. Although Kavita’s case was dismissed due to a major medical procedure, not all surgeries or medical conditions result in dismissal.
Singhal notes, “There are cases where people who have undergone cancer treatment or angioplasty are covered by health insurance. Most health insurance policies cover minor to mild medical conditions. For serious conditions, insurance companies have specialized products to provide appropriate coverage.”
What does full disclosure mean in insurance?
“The insurance contracts are based on the doctrine of ‘Uberrima Fides’, which means that both the insurer and the insured must disclose all material facts truthfully and fully,” explains Shashank Agarwal, a lawyer at the Delhi High Court. This means that the insured must provide accurate information about any risks that may influence the insurer’s decision to provide coverage or determine the premium. In turn, the insurer must clearly explain the policy terms, including any exclusions or limitations.
Common reasons for refusing health insurance
You may be denied health insurance for a variety of reasons, including:
Pre-existing conditions that cannot be covered
Age restrictions
Employment status does not meet the insurer’s criteria
Living in a country where the insurer cannot provide coverage
Risky lifestyle
Poor insurance history
Sanctions
Incomplete application
Insurance companies assess the frequency and severity of future claims. For example, a person in a critical condition is more likely to be hospitalized and therefore more likely to file a claim.
What should you do if you don’t get coverage?
Singhal advises people to get health insurance when they are young and healthy to avoid complications later. If you have a medical condition, consult health insurance experts to find the right plan from the various options.
Specific health insurance policies have been designed for people with high-risk conditions, such as:
1. Star Heart Care: For people with heart conditions.
2. Star Cancer Care: For various cancer treatments.
3. Aditya Birla Activ One and ICICI Lombard Elevate: Coverage of conditions such as diabetes, high blood pressure, COPD and heart disease.
4. Freedom of care: It covers a range of pre-existing conditions and high-risk health conditions.
5. Manipal Cigna Prime Senior Elite: For seniors, including cancer survivors.
What do insurers offer?
Insurance companies may offer specialized products or a counter offer, such as co-payments, disease-specific sub-limits or permanent exclusions. A person with a serious medical condition may develop:
A plan with an extra loading amount
A counter offer with illness exclusions or personal contribution
A specialized plan
“Of late, insurers have started relaxing the criteria and are now covering conditions like diabetes, hypertension and heart disease. The list of diseases that are outright declining has also narrowed,” says Singhal.
What are your legal options?
“As a well-established principle, an insurance contract only becomes binding when the parties agree on the terms. However, if the denial is based on unreasonable grounds, the consumer can approach the ‘Insurance Ombudsman’ for redress,” says Agarwal. .
If you believe your application has been wrongly rejected, know that the Insurance Regulatory and Development Authority of India (Irdai) provides guidelines to avoid arbitrary denials. Insurers must provide detailed reasons for denial and adhere to fair practices.
“Policy holders can seek redress from the insurance ombudsman or through the Consumer Protection Act, 2019,” said Alay Razvi, partner at Accord Juris. He adds that individuals facing denial of health insurance in India should be aware of their rights and the regulatory frameworks in place to protect them.
First print: June 27, 2024 | 1:31 PM IST