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Financial Planner - Answered on Jan 04, 2024

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Asked by Anonymous - Jan 03, 2024Hindi
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Recently, a top-notch insurer rejected my mediclaim for not informing the insurer that I was a non-habitual smoker. While getting the insurance policy I had stated that I was not a smoker but somehow they found out from my friends and family, or not sure from where, that I was a smoker. I was admitted to a hospital for a lung infection recently and they rejected the claim saying that I falsified my personal info. Under what other grounds can insurance companies reject claims?

Ans: Insurance companies can reject claims for various reasons beyond falsified information like undisclosed smoking habits.
Here are eight common grounds for claim rejection. Please do not ignore these if you want your claim settlement process to happen smoothly:

1. Pre-existing conditions: If the policyholder has a pre-existing medical condition that wasn’t disclosed or was misrepresented at the time of purchasing the policy, the insurer might reject claims related to that condition.

2. Policy exclusions: Certain treatments, procedures, or conditions may not be covered by your insurance policy. If your claim falls under these exclusions, it can be rejected.

3. Non-disclosure of information: Besides smoking habits, any undisclosed information relevant to your health or lifestyle (such as pre-existing illnesses, risky hobbies, etc.) that could impact the policy terms might lead to claim rejection.

4. Lapsed or non-payment of premiums: If you fail to pay premiums within the grace period or if your policy has lapsed due to non-payment, claims during that period might get rejected.

5. Policy limits or maximums: If the claimed amount exceeds the policy’s maximum coverage limit, the insurer might reject the excess amount.

6. Fraud or misrepresentation: Any fraudulent claims, providing false information intentionally, or submitting falsified documents can lead to claim rejection.

7. Waiting periods: Some policies have waiting periods for specific conditions or treatments. If a claim is made within this waiting period, it might be rejected.

8. Policy violations: If the claim is in violation of policy terms or conditions, it can be rejected. For instance, seeking treatment from a non-network provider in cases where network providers are mandated.

If your claim has been rejected, review your policy documents thoroughly to understand the grounds on which the rejection was based. It’s also worth considering appealing the decision if you believe the rejection was made in error or if you have additional information to provide. Consulting with a legal or insurance professional might also help navigate the appeals process or understand your rights in such situations.
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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Ramalingam

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Mutual Funds, Financial Planning Expert - Answered on May 12, 2024

Asked by Anonymous - Mar 12, 2024Hindi
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iam holding a health insurance policy from bajaj for 15 lakhs. iam told that one has to disclose ailments if any, while taking policy. i was suffering from high bp when i took policy, but do not remember whether the same had been dic sclosed or not at the time of taking policy. the policy is more than 3 years old, and no claim has been made under this. will in the future my claim for any heart related ailements that i might suffer , gets rejecte by company on grounds that bp was not disclosed while taking policy. 12.03.2024
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

..Read more

Moneywize

Moneywize   |123 Answers  |Ask -

Financial Planner - Answered on Apr 01, 2024

Asked by Anonymous - Mar 31, 2024Hindi
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If I have a chronic ailment (diabetes, BP, thyroid, heart cond ition, etc.) can I still get coverage? Should I inform the insurer? What if I hide this information from the policy issuer?
Ans: Yes, you can still get health insurance coverage even with a pre-existing chronic ailment like diabetes, high blood pressure, or a heart condition. Here's a breakdown of what to consider:

Disclosing Pre-existing Conditions:

• It is crucial to disclose any pre-existing conditions to the insurer. This is because they assess the risk involved in covering you. Hiding this information can lead to claim rejection later.

Coverage for Pre-existing Conditions:

• Most health insurance plans cover pre-existing conditions, but with a waiting period. This waiting period can range from 2 to 4 years depending on the plan and the severity of the condition.
• There are plans that offer coverage for pre-existing conditions from day one, but they typically come with higher premiums.

Finding the Right Plan:

• Do your research and compare different health insurance plans to find one that offers coverage for your specific chronic ailment and has a reasonable waiting period.

Here are some additional tips:

• Be honest and upfront about your medical history in your application.
• Get a copy of the policy documents and carefully review the exclusions clause to understand what is not covered.
• Consider critical illness plans that provide a lump sum payment for specific critical illnesses, including some chronic conditions.
• Remember, transparency is the key. Disclosing pre-existing conditions ensures you get the right coverage and avoid claim rejections later.

..Read more

Ramalingam

Ramalingam Kalirajan  |4660 Answers  |Ask -

Mutual Funds, Financial Planning Expert - Answered on Jun 25, 2024

Asked by Anonymous - Jun 15, 2024Hindi
Money
I am having a health insurance policy of 10 lacs which i ported in the year 2022. After porting, i did not disclose a surgery done on me in 2002 of bile duct reconstruction due to doctor negliegence. Can it lead to claim rejection if the claim is not due to this or should i inform my insurer now for the same. At the moment i am living a healthy life with no medication for that particular issue. Please advice.
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

..Read more

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DISCLAIMER: The content of this post by the expert is the personal view of the rediffGURU. Investment in securities market are subject to market risks. Read all the related document carefully before investing. The securities quoted are for illustration only and are not recommendatory. Users are advised to pursue the information provided by the rediffGURU only as a source of information and as a point of reference and to rely on their own judgement when making a decision. RediffGURUS is an intermediary as per India's Information Technology Act.

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