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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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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.

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K. Ramalingam, MBA, CFP,

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How Do I Address a Missed Disclosure in My Health Insurance Application? Hi, could you please tell me what I should do to get everything sorted out in a proper manner? I bought Star Health Insurance two and a half years ago from an agent residing in our locality. At that time, to be frank, I didn't know much about health insurance. All I knew was that if something happened to me, hospital expenses would be covered by the insurance. In the past few months, through some reels, ads, and financial YouTube videos, I’ve learned a few things about health insurance, such as pre- and post-hospitalization cover, restoration benefit, room rent limit, co-payment, deductible, etc. That's why, on my 3rd renewal, I ported my Star Health Insurance to Niva Bupa. My question is that I used to smoke five years ago, but I didn't mention this on my application when I got health insurance from Star because I wasn't aware that I needed to declare my smoking habits. At the time of my application, I gave all my documents to my agent, and he didn't even ask me if I had smoked before or not; he just processed everything for me. I didn't intend to hide this information, as I was simply unaware. So, what should I do now? It’s my 3rd year, and my two-year waiting period has also been completed. I'm confused about how to handle this. If I report that I used to smoke five years ago, what will happen? Will I have to wait for the waiting period again or not?
Ans: It's important to address the missed disclosure to avoid future complications. Here's what you should do:

Steps to Take
Notify the Insurer:
Contact Niva Bupa and inform them about your past smoking habit. Transparency is key to avoid claim rejection.

Submit a Written Explanation:
Provide a written explanation, stating that the omission was unintentional due to lack of awareness. Mention that you quit smoking five years ago.

Medical Check-Up:
The insurer may ask for a medical check-up to assess any potential risks. This could help avoid future disputes.

No Waiting Period Reset:
Usually, if the insurer accepts your disclosure, the waiting period should not reset. However, confirm this with Niva Bupa to be sure.

Policy Terms:
Review your policy terms post-disclosure to understand any changes or exclusions that might apply.

Handling this promptly and honestly will ensure your coverage remains intact without issues during claim time.

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I have a crush on my colleague recently. We started as a friend but one day we get drunk on one of colleague house. We talk about life and love. I asked about his ex. He told his past relationship story how they break up. I also shared some of my past situationship. We live in a same colony. So we came back home together getting drunk I told him you can lean ur head on my shoulder. And he suddenly lean his head on my shoulder and he was sleeping and I wake him up when we reached our destination. He takes me to my house and I suddenly hold his wrist. I don't why did I hold him and next morning he yes hi (call my name)how are you I didn't respond properly I'm just like yeah good after that he seems to avoid me a lot he didn't talk to me much I caught him looking at me sometimes but it might be coincidence. I think he doesn't like me
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I understand it must all be very confusing but I would suggest not jumping to conclusions. You think he doesn’t like you, but he might be thinking the same since you did not respond to him properly the next day. That could have triggered his current behavior. If you have feelings for him or if you even miss him as a friend, I would recommend you to clear the air with him. Just talk it out- you can explain how things got a little heavy the other day and that’s why you didn’t speak to him nicely and apologize if that made him feel bad. If even after that he continues to avoid you, then you will have better clarity.

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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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