Cashless rejected: Will my insurance claim be settled later?

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Health insurance policies are not easily available if a person is suffering from pre-existing diseases. If for some reason the policyholder does not disclose about it and buys the policy, he or she may face issues when filing for the claim. We had received a query on this subject on Money9 Helpline.

I bought a health insurance policy for my parents 1.5 years ago. While buying the policy it didn’t occur to us to mention that my mother had her uterus removed 15 years ago. She was admitted to the hospital recently for the treatment of Ascites. The insurance company has already denied the cashless claim saying this disease cannot develop in such a short span. It says the policyholder can file the reimbursement but it will be subject to approvals. Is there any merit in my claim? What should I do?

– Vasu Kumar

Expert view

We approached Rakesh Goyal, Director, Probus Insurance, to address the query:

The most common mistake that many policyholders make at the time of buying the policy is non-disclosure or false information about the pre-existing disease or medical condition. Not providing the necessary information in the proposal form can lead to either two conditions – your claim might get rejected or if the policy gets accepted (only under specific cases) then the premiums would be on the higher end. It is ideal to inform the insurance company about the complete details of any medical condition or history while buying the policy to avoid any unpleasant surprises during the claim process. You need not worry if you have mentioned your medical history or any other procedures that you or your family members (in the case of a family floater) are undergoing in the proposal form.

In the above case, the individual and the family were aware of the procedure of uterus removal and still failed to provide this information to the insurance company while buying the plan. Since the insurance company has mentioned that the disease of Ascites cannot be developed in such a short period. Here, there is a high certainty that the medical team would reject the claim during the approval stage, and the insured would be denied to apply for any reimbursement as well. Here, the insured should have mentioned the medical history no matter how long back the medical procedure occurred. This seems to be a non-disclosure situation, and hence there might be no settlements of claim done here. Such a situation can put the insured and the family under tremendous stress and hence should be avoided.