The insurance companies take a decision to provide coverage based on the risk assessment of an individual’s medical condition
)
Notwithstanding the growth in health premiums, insurers have seen elevated levels of Covid claims in the first three months of the financial year due to the second wave of the pandemic.
Kavita, a 34-year-old Pune resident, recently underwent a myotomy laparoscopy. Realising the importance of health insurance after her surgery, she applied to several insurers. However, her applications were rejected. The insurers told her that they would not accept an individual who has had a major surgery.
Have you been denied a policy on similar grounds?
What can you do if you find yourself in a similar situation? Let’s understand the details.
Why do insurers reject applications after surgery?
“The insurance companies take a decision to provide coverage based on the risk assessment of an individual’s medical condition,” says Siddharth Singhal, Head of Health Insurance at Policybazaar.com. While Kavita’s case was rejected due to a significant medical procedure, not all surgeries or medical conditions lead to rejection.
Singhal notes, “There are cases where people who have undergone cancer treatment or angioplasty are covered under health insurance plans. Most health insurance policies cover minor to mild medical conditions. For severe conditions, insurance companies have specialised products to provide suitable coverage.”
What does full disclosure mean in insurance?
“The contracts of insurance are based on the doctrine of ‘Uberrima Fides,’ which means that both the insurer and the insured must disclose all material facts truthfully and completely,” explains Shashank Agarwal, advocate at the Delhi High Court. This means the insured must provide accurate information about any risks that could affect the insurer’s decision to provide coverage or determine the premium. In turn, the insurer must clearly explain the policy’s terms, including any exclusions or limitations.
Common reasons for health insurance denial
You might be denied health insurance for several reasons, including:
Pre-existing conditions that can’t be covered
Age restrictions
Employment status not meeting insurer’s criteria
Living in a country where the insurer cannot provide cover
High-risk lifestyle
Poor insurance history
Sanctions
Incomplete application
Insurance companies assess the frequency and severity of future claims. For example, a person with a critical condition is more likely to be hospitalised and thus more likely to make a claim.
What should you do if you’re denied coverage?
Singhal advises individuals to buy health insurance when they’re young and healthy to avoid complications later. If you have a medical condition, consult health insurance experts to find the right plan among multiple options.
There are specific health insurance policies designed for individuals with high-risk conditions, such as:
1. Star Cardiac Care: For those with cardiac conditions.
Cover amount – Rs 4 lakh
Premium – Rs 29,140
2. Star Cancer Care: For various cancer treatments.
Cover amount– Rs 7.5 lakh
Premium – Rs 36,397
3. Aditya Birla Activ One and ICICI Lombard Elevate: Covering ailments such as diabetes, hypertension, COPD, and heart ailments.
Aditya Birla Activ One cover amount – Rs 7 lakh
Premium – Rs 36,620
ICICI Lombard Elevate cover amount – Rs 7 lakh
Premium – Rs 36,620
4. Care Freedom: Covering a range of pre-existing conditions and high-risk health issues.
Cover amount – Rs 5 lakh
Premium – Rs 26,124
5. Manipal Cigna Prime Senior Elite: For senior citizens, including cancer survivors
Cover amount – Rs 7.5 lakh
Premium – Rs 28,102
aniltikotekar4sme.com 