Claim rejected even after completing Moratorium Period?

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Naman has been paying the premium for health insurance for a long time. Recently, he was hospitalized due to chest pain and had to undergo heart surgery. However, when it was time to pay the bill, the insurance company rejected the claim. Naman has completed the moratorium period, so why was this claim rejected? This remains a question.

What is the Moratorium Period in Health Insurance? How is it different from the Waiting Period? After completing the Moratorium Period, under what conditions can an insurance company still reject your claim? Let’s understand.

What is the Moratorium Period?

The Moratorium Period is a special waiting period imposed by insurance companies. This period is also known as the Look-Back Period. It serves as a safeguard for policyholders. After the moratorium period is over, the insurance company cannot reject a claim based on intentional non-disclosure or accidental omission of a pre-existing condition. Previously, companies used to reject claims by labeling conditions like diabetes, high blood pressure, and asthma as pre-existing. Now, such claims don’t face rejection.

In addition to the Moratorium Period, a health insurance policy also has a specific waiting period for particular diseases, known as PED (Pre-existing Disease) Waiting Period or Cooling-Off Period. After this period, you can claim coverage for specific diseases. When you purchase a policy, you must disclose these conditions in the proposal form.

Earlier, the Moratorium Period was 8 years. Recently, IRDAI has reduced it to 5 years. If you maintain a health insurance policy for a continuous period of five years, your Moratorium Period will be considered complete. Even if you port your policy, it will be considered continuous. In such cases, the insurance company cannot reject your claim.

However, there is one condition here. If the condition you are claiming for is not part of the policy cover, your claim will be denied. Additionally, if you misrepresent the medical condition or hide a health issue when buying the policy, the insurance company may cancel your policy and also seize your premium. However, the insurance company must provide evidence of fraud.

This was the issue with Naman’s claim. Before buying the health insurance policy, Naman had suffered a heart attack and had undergone treatment. When filling out the proposal form, he did not disclose this fact. When this was found during the insurance company’s investigation, they rejected the claim.

Experts say…

Pankaj Rastogi, Director at Midas Finserve, says that certain health conditions require higher premiums for coverage. Some insurance companies even refuse to provide policies for such individuals. Sometimes, insurance agents might advise clients to hide such information while selling policies. When it comes time to make a claim, the insurance company rejects it. To avoid such situations, fully disclose your health conditions when buying a policy and understand the terms and conditions well. Any negligence in this matter can lead to significant issues for you.

Given the rising cost of healthcare, it is very important to get adequate health insurance coverage. When buying insurance, fill out the proposal form yourself. If there is any confusion, contact the insurance company’s representative. Provide accurate information in the proposal form and thoroughly understand the terms and conditions of the policy. Otherwise, you might regret it later like Naman did.