New Delhi. Imagine a disease that occurred years ago and its treatment has been completed. The doctors have also said that everything is fine. You think now it has nothing to do with your life or insurance. But suddenly as soon as you reach to pay the hospital bill, the insurance company stops your claim by citing the same old, dead disease. How will you feel after hearing this? The current IRDAI rules clearly state that insurance companies cannot reject claims in such cases.
According to the Insurance Regulatory and Development Authority (IRDAI), the claim should be decided only on the basis of medical evidence, accurate correlation of the disease and actual risk, and not on the basis of old and irrelevant medical history.
Information about chronic disease was not given while purchasing the policy.
Recently, the company rejected the reimbursement claim of a man for Acute Motor Axonal Polyneuropathy (AMAN) saying that he had been diagnosed with Ankylosing Spondylitis in 2008, which he did not declare at the time of purchasing the policy even though the disease was completely cured years ago and officially confirmed by the doctor. According to experts, in such a situation, the policyholder cannot be expected to consider an old, dead and irrelevant disease as important information.
Direct or indirect relation with the existing disease is necessary
According to insurance law, concealment of any past medical condition is justified only if the disease is active or ongoing at the time of purchasing the policy and has a direct or indirect relationship with the existing disease. AMAN is a neurological problem and ankylosing spondylitis is a rheumatic disease. There is no medical link between the two. In such a situation, the decision to reject the claim is considered weak as per the rules.
5 year moratorium can become your shield
The security becomes stronger after the 5-year moratorium rule of IRDAI. If a policy has completed 5 consecutive years, the insurance company cannot reject the claim on the grounds of past medical history, non-disclosure or incorrect information, except in cases of clearly proven fraud. Even in this case, if the policy was more than 5 years old, then citing old illness is against the rules.
where to complain
Insurance companies should give an opportunity to ask for necessary documents, seek clarification and seek medical opinion before rejecting the claim. Not doing so is against the fair claim handling rules of IRDAI. If the company does not take proper action on the claim, the policyholder can first write to the Grievance Redressal Officer (GRO) of the company. If no response is received, the matter can be taken to Bima Bharosa portal or Insurance Ombudsman.
Bima Bharosa Portal: Just one click and complaint is over!
If you have any problem related to insurance, now Bima Bharosa Portal is ready to help. This is the new portal of Insurance Regulatory and Development Authority of India (IRDAI), which has replaced the old IGMS system. After filing the complaint here, you get a tracking number and your case keeps getting updated from the systems of both the online insurer and IRDAI.
How to complain through Bima Bharosa portal
- Go to Bima Bharosa website and select Register Complaint.
- Create a profile by entering name, mobile and email.
- Select your insurer, enter the policy or claim number.
- Write the problem clearly and upload the necessary documents.
- After submitting, you will get a tracking number from which you can see the progress – like New, Attended or Closed.
