There are enough loopholes for claim rejections even after standardization of health insurance terms by the Insurance Regulatory and Development Authority -IRDA. This was found especially in the case of personal accident and critical illness covers.
"Although health insurance is rapidly growing, access to it still remains limited and complaints, especially due to variable interpretations of key policy terms, are enormous," it explained. "All insurers shall adhere to the stipulated definitions, while defining these 46 core terms in all policies," it said.
Should the deciding factor be the doctor or the insurer? In this case Mr. Kumar's wife had high fever for 4 days the ensuing blood test showed symptoms for both malaria and typhoid. On the doctor's advice Mr. Kumar admitted his wife to hospital in a bid to control the fever.
The insurer refused Mr. Kumar's claim saying hospitalization was not required and the health insurance plan did not include medical expenses. On the basis of a doctor's advice hospitalization was imminent.
A clause in the critical illness plan is 'failure to seek or follow medical advice'. Deepak Yohannan of MyInsurance.com feels it's difficult to say the clause is not right. "Because, taking from the clause, delay in taking medical help escalates the cost of treatment, which makes it expensive for the insurer for no reason from their side."
Health insurance experts feel that the insurers cannot raise questions on a doctor's recommendation.
Many times even standardized definitions can be can be open ended and lead to claim rejection. Yashish Dahiya of policybazaar.com feels "One such example is the definition of pre-existing conditions. Irda defines or standardizes a pre-existing condition as 'previous hospitalization or medical treatment due to an injury or medical condition within the last 48 months of the policy being issued'. This statement is very insurer specific as at times a pre-existing ailment can precede the specified 48 months.
Another example is the definition of something as simple as 'injury'. This means 'accidental physical bodily harm, excluding illness or disease solely and directly caused by external, violent and visible and evident means, which is verified and certified by a medical practitioner'. M S Kamath, a medical practitioner and general secretary of the Consumer Grievance Society of India, said by such definitions, even a simple sprain should be covered under health insurance. That is not the case.
Under symptoms of critical illness which existed before the inception of the policy, which the insured may not even have been aware about and manifests within three months of a valid policy is then left to the insurer to accept or reject claims.
Hannah Punitha (IRDA Licence Number: 2710062)
Neha Pandey Deoras, July 2014