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Insurance Expert - Answered on Oct 12, 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 Syamala on Oct 12, 2022Hindi

I understand that on completion of continuous 8 years of renewal of health care insurance, insurers cannot reject an eligible claim. Is this correct?

I took a health policy from Max Bupa in Aug 2016 and continued renewal for 4 years until Aug 2020 post which I ported my policy to another company for a period of 2 years.

Will this be considered as 6 years of continuous renewal of my policy or will porting have an impact on the continuity period?

Ans: Hi Syamala, to answer your first query, your understanding is correct.As mandated by IRDAI, a health insurer cannot reject an eligible claim if the policy has completed 8 years of renewal.

This period of 8 years is called Moratorium Period.

Except for proven fraud and permanent exclusions specified in the policy contract, no health insurance claim shall be contestable after the Moratorium Period expires.

The policies, however, would be subject to all policy limits, sublimits, co-payments, and deductibles.

As you have mentioned that you ported the policy after 4 years, it will not be an issue as porting is also considered continuous renewal.

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 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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Answered on Aug 03, 2021

Question by Gautam - Aug 03, 2021Hindi

If you can kindly tell something on 8-year clause by IRDA. Can the health insurance claim be rejected even after 8 years of paying continuous premium without any claim taken?

Ans: The clause is termed as ‘Moratorium Period’ and according to this after the completion of 8 continuous years no health insurance claim shall be contestable for non-disclosure of relevant information at the time of policy issuance except for proven fraud and permanent exclusions specified in the policy contract.

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Question by Narayan - 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.

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Question by Gora - Nov 24, 2022Hindi

I was customer of Oriental Bank of Commerce. Being a customer of Oriental Bank of Commerce, Oriental Insurance Company provided Group Health Insurance Policy and inception date was 04-05-2015. My policy with them continued till 03-05-2021 without any break. Because Oriental Bank of Commerce merged with Punjab National Bank, Oriental Insurance Company discontinued that policy from 03-05-2021 onward. Being a customer of Punjab National Bank, I approached them, and they migrated my Group Health Insurance Policy of Oriental Insurance Company to Star Group Health Insurance Policy for customers of Punjab National Bank from 04-05-2021 to 03-05-2022. As All my policy periods were continued from 04-05-2015 till 03-05-2021 with Oriental Insurance Company, Star Health Insurance given me the benefit of pre-existing disease waiting periods being waived because of continuity (They mentioned it in Policy Document too). They reimbursed my 1st claim of 15 July to 22 July 2021 (Non Empaneled Hospital) and Cashless claim of 16 December to 19/12/2021 but denied reimbursement of 19/12/2021 to 26/12/2021 with the excuse of pre-existing disease even I directly shifted from cashless hospital to non-Empaneled Hospital for same problem because Empaneled hospital having been less facilities. Here I want to address that I was discharged from Cashless Hospital, on request, to get treated in Higher Hospital and treatment was in continuation of previous cashless hospital to new hospital. So, sir, please guide me accordingly as my correspondence with them is not fruitful.

Ans: Hi Gora Lal Gargi, to solve your query I will need more information. Firstly, please do check if your sum insured value was exhausted in the first claim.

If yes, then check the policy document to know if your insurer provides claim for same person, same illness on the second claim i.e. restoration benefits.