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In a world that worships achievement, gratitude is an underrated sentiment. Yet, let me dedicate this instalment of Cover Note to key issues in health insurance that have been clarified, defined, and codified so that the insured, that is you and me, now take it for granted. Moreover, our expectations go beyond then quickly. However, that is human nature, and it is what leads to progress.
To improve we must be able to measure, and for that we need definitions. Guidelines on Standardisation in Health Insurance were issued on July 29, 2016 by IRDAI where definitions of what a pre-existing disease is were codified. Before that claim-time interpretations ruled and, invariably, the insured was at the losing end. The definition then was, “Pre-Existing Disease means any condition, ailment or injury or related condition(s) for which there were signs or symptoms, and/or were diagnosed, and/or for which medical advice/treatment was received within 48 months prior to the first policy issued by the insurer and renewed continuously thereafter.”
As an insured, if you are buying a new policy, you should declare any pre-existing disease like heart conditions, cancer, blood pressure, diabetes and so on, which can have long-term or serious effects on health.
The insurer does have the right to refuse your proposal of insurance. If he offers cover, it can be at a premium rate at his discretion. Once you get the policy, any claims for the PEDs will not be payable for a waiting period of four years, the maximum allowed by the regulator. Claims after the waiting period are payable provided you have made this declaration.
This brings us to the next matter. In those days, once a claim is paid, insurance companies were known to dodge renewal. The same was the case with ageing insureds. Perceiving a higher risk of hospitalisation as an insured got older, insurance companies would refuse renewal.
The regulator mandated in 2016 that insureds are entitled to life-long renewal of their hospitalisation policies, except in cases of misrepresentation or fraud, thus lifting a mental and financial pressure that sets in at old age. Remember yet that there are age caps for taking a new policy and that life long renewability still means you have to remember to renew in time!
(The writer is a business journalist specialising in insurance & corporate history)
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