58-Year-Old With Hypertension Denied Coverage - Fair or Not?

Ans: Hi Mr. Tripathi, greetings to you. To answer your first question as to why Aditya Birla won’t provide you with cashless claim as opposed to TATA AIG is because the policy you bought from Aditya Birla is a ‘Super top up plan’ which basically means it is an addition to your base policy which in your case is your TATA AIG policy.

Super top up policies do not offer cashless claims but only provide reimbursements.

The one lakh gap, unfortunately, cannot be filled at this point. However, while renewing your policy you can opt for increased sum insured with TATA AIG. The insurer will ask you a set of questions and schedule medicals to analyse your risk profile. Post that based on your reports, the insurer will take a decision on increasing the limit.   

Ans:  Coverage pertaining to Aortic Valve Replacement for the Heart will depend on the nature and duration of the illness. Your insurance company will ideally seek clarification on the cause and duration of the illness. Basis the medical documents you submit at the time of claim, if it is observed that your medical condition is not a pre-existing one, nor an effect of Hypertension, then your claim should be considered.

Ans: If the values are within limits you need not disclose it, but you must clarify upfront regarding any family history of cardiac problems in your lineage.

Ans: It's essential to be transparent about pre-existing conditions like high blood pressure (BP) when applying for a health insurance policy. While I can't provide a definitive answer without reviewing your policy documents and the specific terms and conditions, here's some guidance:

Review Policy Documents: Take some time to carefully review your health insurance policy documents. Look for any clauses related to non-disclosure of pre-existing conditions at the time of policy issuance.

Contact the Insurer: If you're unsure whether you disclosed your high BP when taking the policy, consider reaching out to the insurance company directly. They can provide clarity on the information provided during the application process.

Grace Period: Since your policy is more than 3 years old and you haven't made any claims, it's possible that any non-disclosure issues may be considered lapsed due to the grace period typically provided by insurers.

Future Claims: In the event that you develop heart-related ailments in the future, the insurance company may investigate whether the non-disclosure of high BP was intentional or unintentional. If it's determined that the non-disclosure didn't affect the underwriting decision or the terms of the policy, your claim may still be honored.

Seek Professional Advice: If you're concerned about the potential impact of non-disclosure on future claims, consider consulting with a legal or insurance expert who can provide personalized guidance based on your specific situation and policy terms.

Ultimately, it's crucial to maintain transparency with your insurer and ensure that all relevant information, including pre-existing conditions, is disclosed at the time of policy application to avoid any complications during claim processing.

Best Regards,

K. Ramalingam, MBA, CFP,

Chief Financial Planner,

www.holisticinvestment.in

Ans: You have a health insurance policy with a coverage of Rs 10 lakhs, which you ported in 2022. However, you did not disclose a bile duct reconstruction surgery done in 2002. Now you’re concerned about claim rejection due to this undisclosed surgery, even if the claim is for an unrelated issue. Let's address your concern comprehensively.

Importance of Disclosure in Health Insurance
Health insurance relies heavily on the principle of utmost good faith. This means both the insurer and the insured must disclose all relevant information truthfully. Non-disclosure of medical history can have serious consequences.

Impact of Non-Disclosure
Claim Rejection: Insurers can reject claims if they find out that significant medical history was not disclosed. This applies even if the claim is not related to the undisclosed condition.
Policy Cancellation: In some cases, the insurer may cancel the policy altogether upon discovering non-disclosure.
Legal Issues: Non-disclosure can lead to legal complications where the insured may face difficulties in proving their claim.
Assessing Your Specific Situation
Your surgery was in 2002, and you are currently healthy with no ongoing medication related to that issue. Given this, let’s analyze your situation.

Time Factor
The surgery happened over 20 years ago, and you have been living a healthy life since then. This long duration might make it less impactful, but it’s still a significant medical event that should have been disclosed.
Porting Health Insurance
When porting a health insurance policy, the new insurer evaluates your health risk based on the information provided. Non-disclosure of a major surgery might influence their decision on claims and policy terms.
Steps to Take Now
Inform Your Insurer
Contact Your Insurer: It's advisable to inform your insurer about the surgery. Explain the situation honestly, including that the surgery happened in 2002 and you have had no related health issues since.
Provide Medical Records: If possible, provide medical records or a letter from your doctor confirming that you have fully recovered and have no ongoing health issues related to the surgery.
Benefits of Informing Your Insurer
Transparency: Being transparent can build trust with your insurer and prevent future complications.
Reduced Risk of Claim Rejection: Disclosing now can reduce the risk of future claim rejections due to non-disclosure.
Policy Review: The insurer might review your policy terms, but it’s better to face this now rather than during a claim.
Possible Outcomes
Policy Continuation: The insurer may continue your policy without any changes if they consider the surgery as not impacting your current health risk.
Policy Amendment: The insurer might amend the policy terms, such as excluding the surgery-related condition from coverage.
Premium Adjustment: In some cases, there might be an adjustment in the premium based on the newly disclosed information.
Importance of Maintaining Adequate Health Insurance
Reviewing Coverage
Ensure that your health insurance coverage is adequate for your current needs. A family floater policy of Rs 10 lakhs might be sufficient now, but review it periodically to keep up with rising medical costs.
Considering Top-Up Plans
If needed, consider top-up or super top-up health insurance plans to enhance your coverage at a lower additional premium. These plans provide additional coverage after your base policy limit is exhausted.
Staying Informed and Proactive
Regular Policy Review
Review your health insurance policy annually. Ensure all details are accurate and up-to-date. Discuss any changes in your health status with your insurer.
Keeping Medical Records
Maintain a file of all your medical records. This helps in providing accurate information to your insurer and simplifies the claims process.
Understanding Policy Terms
Thoroughly understand the terms and conditions of your health insurance policy. Know what is covered, what is excluded, and the process for making a claim.
Final Insights
Transparency with your insurer is crucial for ensuring your health insurance policy serves its purpose effectively. Informing your insurer about your past surgery, even if it was 20 years ago, will help in maintaining a trustworthy relationship and avoiding potential claim rejections.

With a comprehensive approach to managing your health insurance, including regular reviews and staying informed about your policy, you can ensure you and your family are adequately protected.

Best Regards,

K. Ramalingam, MBA, CFP,

Chief Financial Planner,

www.holisticinvestment.in