Health insurance: How to ensure that your claim is not rejected due to pre-existing illnesses

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Not so long ago pre-existing diseases was a cause of concern for both customers and insurance companies as each company’s definition was based on their underwriting principles. Now with a maximum of 48 months, the waiting period has been clearly defined for pre-existing illnesses leading to lower bottlenecks during claim settlement processes.

According to the Insurance Regulatory and Development Authority of India (IRDAI), pre-existing diseases has been defined as any condition, ailment or injury or related condition(s) for which the insured had signs or symptoms, and/or was diagnosed, received medical advice or treatment within 48 months (four years) prior to the first policy issued by the insurer.

For example, a person had heart problems in the past but later got cured and didn’t take any medical help prior to four years of taking the policy. Is it considered a pre-existing illness? In this case, the heart condition mentioned will not be considered as pre-existing as four years have elapsed before buying the policy. But the customer is expected to declare this condition while filling the proposal form. Moreover, the issuance of a policy depends on the risk appetite of the insurer.

Things to ensure smooth claim settlement process

Health declaration: One should not hide any information or overwrite on the proposal form. The correct and authentic information should be shared with the insurer so that there are no surprises later. Misrepresentation of facts or exclusion of medical conditions can later lead to delay or rejection of the claim. Hence, always fill the proposal form correctly.

Documents: It is often seen that people do not submit documents immediately after being discharged from the hospital. This can be a costly mistake as insurers have a time limit of 7-15 days for the submission of documents. In order to ensure quicker claims settlement policyholders should provide all the required documents quickly and completely to the insurer.

Fine prints: Before buying a policy it is important to have a clear understanding of the policy. The prior knowledge of benefits, exclusions and waiting period can give the policyholder a good idea of claimable expenses leading to a smoother claim process.