I am a mild smoker aged 47 years. I am already having medical insurance for the past 10 years. When I tried to include the concept "smoker" in the renewal application, the agent does not accept and want us to lie with the insurance company. In view of the above the real truth is not disclosed. In this situation, whether any claim particularly related to heart or BP or hospitalization will be affected? Whether full claim will be affected? Please clarify sir.

If I particularly want to include the smoker in the application, whether the premium will be high?

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.

Ans: Hi Satish, health insurance has to be claimed in the year when the medical expenses were incurred. If the base policy coverage for that year's expense is exhausted and there is no top up plan in support to base policy, then the claim settlement will become an issue as the limit is over. It cannot be adjusted in the next year.

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.