What are the basic parameters that help avoid claim rejection?

First and foremost, it is always recommended to disclose current and past medical history of all the members involved in the policy. If you are suffering from diabetes, hypertension, heart condition, or have had any surgeries, or any sort of fractures in the past, or some serious medical conditions, these should be disclosed. Also, one must disclose any lifestyle habits like, smoking or alcohol consumption. Second, one must understand waiting periods. There are three types of waiting periods. One is the initial waiting period of 30 days, during which only accident related claims will be accepted. Then, there are slowly advancing illnesses waiting period, which includes, cataracts, hernia, knee replacement and others which will have a 2-year waiting period. Then, there is a 3-year waiting period for any illness which existed at the time of buying the policy, called pre-existing illness/disease (PED). Waiting periods and full disclosure are the two basic conditions, once met, should significantly lower the chances of claim rejection.

There could be cases where one forgets a doctor consultation three years ago or is unaware of a condition. How far back does one have to go for disclosure of medical conditions?

Chronic illness and hospitalisations must be declared. But if somebody is actively unaware of the condition, obviously that is something that a person cannot disclose. Regarding doctor consultations, if it is a regular feature, then you should declare it.

Sub-limits on coverage for cataracts, maternity or knee replacement seem to be a problem faced by policyholders repeatedly. Where can one find complete information on sub-limits within a policy?

Some of the earlier plans had a lot of sub-limits including room rents (₹5,000 per day). These plans would have proportionate deduction from the claim and not just room rent. Most of the plans now offer a single private AC room which should be preferred. The second type of sub-limit is treatment-specific which caps the claim amount on cataracts to ₹50,000 per eye or knee replacement to ₹1-2 lakh. But now most of the new-age plans have done away with those limits as they create friction at the time of claim. Now, in fact, you would see a lot of knee replacement bills as high as ₹8-9 lakh which are again paid to the customer. So, I think it is better to assess your policy and upgrade to a better plan, which does not have any such sort of sub-limit. One can find information on sub-limits in the policy copy or the digital copy where you can search for sub-limits or you can find it in customer information sheet, where crucial information pertaining to policy is given and must be reviewed.

The other point of friction is when the insurer rejects a claim on medical basis such as hospitalisation is not necessary or treatment method is not compliant. How to resolve such issues?

Obviously, the revenue model for hospitals is different from insurance. So, I think here the role of broker, the intermediary and a player like Policybazaar comes into the picture which can take an independent stand whether it was required or not required, and such cases can certainly be contested. When purchasing a policy it is important to buy from an institution that has claims experience. Also, if you are going for a hospitalisation, it’s always important to inform your insurance company first. In case of an emergency as well, one should inform the insurance company within 24 hours of hospitalisation. In case of a divergence in medical opinion at the time of the claim, there are redressal mechanisms such as producing more evidence from the treating doctor, raising the issue to the grievance officer or ombudsman. Then, there is the court of law where issues should be resolved. Most cases get resolved at the lower levels.

With claim handling in mind, there is a view that an agent-assisted policy purchase can be beneficial at the time of claims handling. As an online business, how would you counter that?

I would say that it is a slightly oldish perception and that is also changing very fast. India is a huge market for sure, and obviously, agents are also doing their part in propagating insurance. But as a large company, we work with all insurance firms and have developed claims expertise. Roughly, we have about 600-odd people in the in-house claims team which looks at customer claims, what is the procedures of claims, where it could get stuck and documentations required and so on. Wherever required, we fight with the insurance companies. So, I think that is where online space becomes important.

Claims made after the moratorium period of five years cannot be rejected? Are there any obstacles even after moratorium period?

Yes, moratorium period is a great initiative. After five years, your claim cannot be rejected unless it is proven to be fraudulent. Otherwise, after five years, the claim cannot be rejected.

Policyholders who ported their policies often complain that even after completing or serving a part of the PED waiting period, claims are being rejected. What could be the reason?

There is a confusion which happens at the time of porting, regarding disclosure. This is because at times a customer may feel that they had declared this condition to their previous company, so they don’t need to declare it again to the new company. But it is always important to declare any new medical conditions or any past medical conditions at the time of porting. So, if you’ve already, let’s say, served three years in your previous policy, then those three years will get carried forward for sure. But this will apply only to the original sum insured. If a higher sum is taken in the new policy, then waiting period will apply to the difference.

Any other point you would like to highlight for a safe claims process?

As mentioned, understand the waiting periods, make the right disclosures and buy from a solid intermediary. Also, adding a few riders would improve the claims experience. Day one covers reduce waiting periods for diabetes, high blood pressure, or other ailments from three years to 30 days. Consumables cover is also important as close to 8-10 per cent of the hospital bill for kits, gloves and covers are not covered without the rider. Look for plans that have very few or no sub-limits for any disease. These should significantly improve the claims experience.