My wife underwent TAVI procedure and our entire Insurance has been absorbed @ settlement of claim by Insurance company.Till October end, we dont have any insurance coverage. Being a retired banker, my insurance Company IBA is National Inaueance- thier TOA Medi Assust. My question is 1) whether any other ibsurance taken will cover both if us fron now inwards. 2) whether my wife will be covered from November and denied @ pre medical hospitalisation and surgery done

Ans: It is good that you are checking this now rather than waiting until November. After a major cardiac procedure, continuity of the existing health cover becomes very important. Your two questions also need to be treated separately: taking a new policy now, and restoration of cover under your existing retired-bankers group policy from November.

» Can You Take Another Health Insurance Policy Now?

– Yes, you can apply for another health insurance policy for yourself and your wife.

– But applying for insurance does not mean the insurer has to issue the policy on standard terms.

– Your wifes recent TAVI procedure and underlying heart condition must be fully disclosed in the proposal form.

– The new insurer will assess age, medical history, current health, medicines, previous hospitalisation and treatment records.

After underwriting, the insurer may:

– Accept the proposal.

– Ask for medical tests.

– Apply waiting periods as permitted.

– Offer cover with specific terms.

– Apply co-payment or other conditions, depending on the product.

– Or decline the proposal based on its underwriting policy.

So yes, you can apply. But do not assume that a newly purchased policy will immediately cover treatment connected with the recent heart condition.

» A New Policy Will Normally Treat the Heart Condition as Pre-Existing

This is very important.

Your wife has already undergone TAVI.

Therefore, when applying for a fresh policy, her cardiac condition, diagnosis, hospitalisation and surgery are already known medical history.

A fresh insurer will generally assess this as a pre-existing medical condition.

The insurer may cover the condition only after the applicable waiting period and subject to the policy terms and underwriting decision.

A new policy normally cannot be expected to pay retrospectively for treatment that happened before the policy started.

» Please Disclose Everything

Do not leave out the TAVI procedure because you are worried that the new insurer may reject the proposal.

Disclose:

– Heart condition.

– TAVI procedure.

– Hospitalisation dates.

– Current medication.

– Follow-up treatment.

– Other existing medical conditions.

– Previous insurance claims.

– Current insurance details.

If important medical information is hidden, a future claim can become much more difficult.

A policy issued after full disclosure is far more useful than a policy obtained by incomplete disclosure.

» Your Existing Cover From November Is a Different Matter

You mentioned that your current insurance limit has been fully utilised and the next coverage becomes available from November.

If this is the continuation/renewal of your existing retired-bankers group medical cover, your wifes situation can be different from taking a completely new retail health policy.

The important questions are:

– Is the policy continuing without a break?

– Is November the normal renewal date?

– Will the sum insured simply get refreshed on renewal?

– Does the existing policy continue to cover pre-existing diseases?

– Are there any restrictions after the sum insured has been exhausted?

– What are the rules for repeat treatment relating to the same cardiac condition?

– Is there any restoration/reinstatement benefit during the current policy year?

You need written clarification on these points.

» Previous TAVI Should Not Automatically Mean Future Claims Are Denied

If your wife remains continuously insured under the same group arrangement after renewal, the fact that she underwent TAVI earlier does not automatically mean that every future cardiac claim will be rejected.

But future treatment must satisfy the terms of the renewed policy.

For example, the insurer/administrator may examine whether a future hospitalisation is:

– A fresh medically necessary hospitalisation.

– Follow-up treatment.

– A complication of the earlier procedure.

– Part of the original hospitalisation episode.

– Covered under pre/post-hospitalisation provisions.

– Subject to any specific limit or exclusion.

Therefore, please do not rely only on a verbal statement saying "coverage starts again in November."

Get confirmation in writing.

» Pre and Post-Hospitalisation Need Special Attention

You asked whether your wife could be denied because the original hospitalisation and surgery happened before November.

This depends on what exactly you claim after November.

Expenses relating to a hospitalisation that occurred in the previous policy period do not automatically become a fresh claim simply because a new policy year starts.

Pre-hospitalisation and post-hospitalisation expenses are normally connected to the underlying admissible hospitalisation and are subject to the policy wording and specified time limits.

So, if the current sum insured has already been exhausted, do not assume that old treatment bills can simply be submitted again after the sum insured refreshes in November.

On the other hand, a genuinely new hospitalisation after renewal may need to be assessed separately under the renewed policy terms.

» Check Whether Any Restoration Benefit Exists Now

Before assuming that you have zero protection until October-end, check the present policy carefully.

Some health policies/group arrangements may provide restoration or reinstatement of sum insured after exhaustion, subject to conditions.

The restored amount may have restrictions regarding:

– Same illness.

– Same person.

– Related complications.

– Timing of restoration.

– Number of restorations.

– Maximum amount.

Your particular group policy may or may not provide this facility. So ask the insurer/administrator specifically rather than assuming there is no cover left.

» Portability or Migration Needs Careful Handling

If you are thinking about moving from the existing group cover to an individual/family health policy, ask about portability/migration possibilities and continuity benefits.

Previous continuous insurance history can sometimes help with waiting-period credits, subject to regulations, policy conditions and underwriting.

But after a major recent cardiac procedure, do not cancel or allow the existing cover to lapse merely because you have applied elsewhere.

First get the new policy issued and understand its conditions in writing.

Continuity of health insurance at your stage of life is extremely valuable.

» Consider Separate Policies for Husband and Wife

Depending on your ages and medical histories, also evaluate whether separate individual covers are more suitable than putting both of you under one shared family floater.

Why?

If one spouse has a major medical requirement, a shared sum insured can potentially get heavily utilised.

Separate covers can sometimes provide better segregation of medical risk.

But this depends on premium, underwriting, age, medical history and policy terms.

So compare the structure, not only the premium.

» Build a Medical Emergency Corpus Also

Your present experience shows why insurance alone should not be the only protection.

Even with health insurance, there can be:

– Co-payments.

– Non-medical expenses.

– Exclusions.

– Sub-limits.

– Treatment outside policy conditions.

– Periods when the available sum insured is exhausted.

As a retired person, maintaining a separate liquid medical emergency corpus can provide an additional layer of protection.

This money should remain relatively safe and easily accessible. It is not money to chase higher investment returns.

» What You Should Do Immediately

I would suggest the following:

– Get the current policy wording and November renewal terms.

– Ask the insurer/administrator in writing whether your wife will continue to be covered for the existing cardiac condition after renewal.

– Ask whether a fresh hospitalisation related to the heart condition after November will be covered.

– Ask whether any restoration/reinstatement benefit is available before October-end.

– Ask how post-hospitalisation expenses relating to the TAVI procedure will be handled.

– Apply for additional health insurance now rather than waiting until November, but disclose the complete medical history.

– Do not discontinue the existing group cover while exploring alternatives.

– Keep a separate liquid medical reserve.

Keep the written replies carefully. In health insurance, written policy terms and written insurer communication matter much more than verbal assurance from an agent or helpdesk.

» Final Insights

Yes, you and your wife can apply for another health insurance policy now. But because your wife has already undergone TAVI, a new insurer will consider her existing cardiac history during underwriting. Immediate unrestricted coverage for that condition should not be assumed.

Regarding your existing retired-bankers cover, if it renews continuously in November, your wifes previous TAVI does not by itself mean that she loses all future coverage. But whether a future cardiac treatment is payable will depend on the renewed policy terms, continuity of coverage and nature of the future claim.

Most importantly, do not allow the present policy to lapse while searching for another option.

Maintain continuity, explore additional coverage with full disclosure and create a separate medical emergency corpus. After experiencing one major claim that exhausted the available cover, having these multiple layers of protection becomes particularly important.

Best Regards,

K. Ramalingam, MBA, CFP,

AMFI-Registered MFD – ARN 4188

www.holisticinvestment.in

https://www.linkedin.com/in/ramalingamcfp/