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Insurance Expert - Answered on Sep 08, 2022

Sanjib Jha is the CEO of Coverfox Insurance. His expertise includes health and auto insurance. He has over 22 years of experience in the financial sector. He has completed his post-graduation from the Institute of Company Secretaries of India.... more

Question by Narayan on Sep 08, 2022Hindi

I have a health insurance policy, running continued from 2012 without any claim up to 2022. In 2021, I ported it to another company.

Unfortunately, this year in April my son was diagnosed with Crohn's disease and required repeated hospitalisation. Expenses were taken care of by the insurance company. Now my doubts are:

1. My son is advised to have an injection every 8 weeks continuously for next 2 years. This is expensive and will be done in PICU as a day-care procedure. It might take 10 to 12 hours for the procedure, to be done in PICU (He is 14 years old). How I can get these expenses covered by my insurance.

2. Is there any limit on number of claims, in a year, as I already have many this year?

Is there any possibility, that my insurance company might deny the next renewal due to more number of claims?

Ans: Hi Narayan, my best wishes to you and your family. To answer your questions, if your policy has Day Care treatment included in the policy document, then the same can be claimed for. There is no limit to the number of claims taken in a year. However, you can only apply for claims only up to the sum assured value of your health policy.

As far as insurer denying renewal due to number of claims, the answer is no, insurer will not deny your renewal. However, there is a possibility that the insurer will increase your yearly premium based on the re-evaluated risk.

DISCLAIMER: The content of this post by the expert is the personal view of the rediffGURU. Users are advised to pursue the information provided by the rediffGURU only as a source of information to be as a point of reference and to rely on their own judgement when making a decision.

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Question by S - Jun 21, 2022Hindi

Dear Sir, Greetings of the day. I have got a health insurance of family floater type from Tata AIG for a sum of four lakhs. Recently, I got hospitalised and full four lakhs was paid by Tata Aig. But my hospital bill was six lakhs and sixty two thousand. So there was a shortfall of two lakhs sixty-two thousands. I have an Aditya Birla health Policy of family floater type for 45 lakhs. But it will come in to effect after 5 lakhs expenditure. So I myself paid one lakh from my pocket. And for rest one lakh sixty two thousand only I applied for cashless to Aditya Birla .But they denied it. Finally I paid that amount myself and came home. Afterwards I kept continuous follow up with them. Reconsideration and reminder letter was sent by TPA and Treating doctor. But again it was rejected. Now Aditya Birla employee is saying apply for reimbursement. When Tata Aig is clearing full amount, how come Aditya Birla is denying it? And how can I bridge the gap one lakh between two policies? Tata Aig says you have taken full claim so we cannot make your limit from four to five lakhs this year. Pls advise suitably. Best Wishes

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.

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Insurance Expert - Answered on Jul 29, 2022

Question by Murali - Jul 29, 2022Hindi

I have a unique situation and so a unique query. I have a medical insurance and a top up insurance since 2020 for my family of 4 (me, my wife and 2 children). I have renewed it on time so far. The current renewal is due soon. Meanwhile, I had to travel to the USA to meet my family, where my wife is employed on non-immigration visa for short term, with employer insurance for her and the family. During my stay in the USA, I unfortunately had a massive heart attack. The insurance took care of the expenses as per the policy. My question is, when I come back to India, will the insurer cover me for this heart attack (does it become pre-existing now?), related treatment expenses? What are the IRDAI guidelines for such cases? What are my responsibilities? Will premiums increase? Will waiting period increase? Hope you can help.

Ans: Hi Murali, sorry to hear about your health and wish you a speedy recovery. To answer your question, if there is no waiting period for heart attack in your policy then the same will be covered in the policy for any treatment done in India.

I suggest you to kindly declare the said ailment to the insurer. The premium will not increase considering this factor as the said ailment occurred after the policy issuance.

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Question by Pradeep - Oct 12, 2022Hindi

I am an employee of central govt. PSU. My family consists of myself, spouse, two minor children and mother. I am covered by a corporate group medical insurance policy for Rs 2 lakh with an additional emergency coverage of Rs 4 lakh by the employer. I also have a personal Family Floater policy for Rs 3 lakh and a Sr. Ctzn. Policy for Rs 1 lakh. I have not used the personal policies till date for any hospitalisation claim. I am aware that a claim exceeding the corporate policy limit can be claimed in the personal policy. Recently I was made to know that any planned hospitalisation exceeding the corporate claim limit, cannot be done using the second policy. I also know that there is a product called as top up policy which can be used in such cases. I have 8 years of remaining service where there is a medical insurance cover during the period. After retirement, the employer provides a basic policy of 1.5 lakh for the family. The same feels to be insufficient in today’s times. What would be your advice with regards to the existing medical insurance policies and their amounts? Should I need to undertake any tweaking of the policy amounts or switch to a top up policy?

Ans: Hi Pradeep, yours is a legit concern. It would be best if you take advice from a professional person or company – having the necessary qualifications -- after discussing your issue with them.

Insurance is each to its own. Depending on your concerns and requirements a professional service provider will be able to give you the best advice, whether to tweak policy amount or switch to top up.

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