My son, aged 23 years, was born with a congenital heart disorder which was treated fully within the first year of his birth. He is off medication, except SOS tablets for anxiety. I get him checked every year as a matter of abundant caution. When I declare this as a PED, no insurer is ready to provide him with health insurance, even with the maximum waiting period. I have been refused verbally by insurers. Are they right in refusing insurance to a needy individual? If no, who should I approach for redressal of this grievance? Also, I am apprehensive that these insurers may never give the refusal to me in writing. 

Rajesh

Pankaj Goenka, Vice President and Head, B2B2C at Insurance Dekho

Navigating health insurance for individuals with a history of medical issues is a challenging problem, particularly when it comes to congenital disorders and related health issues.  Currently, insurers typically have a maximum waiting period of three years for pre-existing conditions. However, their actual decision to provide coverage could be dramatically different from one insurer to another, based on the underwriting assessment.

There are three prime factors considered by the insurance companies: past medical treatments, the current health condition of the said individual, and the future outlook regarding that particular medical history. In your son’s case, though his congenital heart disorder was treated completely, insurers may still be concerned about his medical history and the frequency of his current medication for anxiety. If their risk underwriting model is throwing up some notion of risk, they will choose to decline to cover or exclude the cover for a particular disease permanently.

Most insurance companies also have a written clause stating permanent exclusion for congenital diseases.

Under the older regulations, insurers are not always required to provide formal written explanations for their decisions under older regulations. This can lead to frustration, especially when clarity is needed for understanding the basis of a refusal. The lack of written communication can complicate the process of addressing grievances or seeking alternative coverage.

Talking from the perspective of an insurance company, it is important to note that since the decision to accept or reject is based on a lot of complex variables in underwriting, it is also difficult to provide a specific reason for the rejection of a particular case.

But when you are on the receiving end of such rejections from the insurance companies, it is easy to feel cheated. Insurance regulator IRDAI has done a commendable work to ensure the rights of customers are protected in such cases.

Grievance redressal

Usually, the first point of contact for such cases is the Grievance Redressal Officer. Each insurance company has a designated Grievance Redressal Officer. Reach out to them directly to discuss your son’s case and express your concerns. This step is crucial, as it may lead to a more thorough review of his application.

If you are unable to find a satisfactory response from the insurance company, you may visit the IRDAI Web site. Their “Grievance Redressal” section offers information on how to lodge complaints against insurers in case you believe your case has been unfairly treated.

You can also seek some other coverage options such as critical illness insurance or specialised health plans that might have different underwriting criteria. However, most companies have similar stringent criteria and requirements for alternative treatment plans and you might not find much success here.

Hopefully, this information would enable you to move forward and find an apt solution to this problem.

The writer is Vice-President and Head - B2B2C, Insurance Dekho

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