Denial of health cover still rampant

Amit Kumar ( 27), a corporate executive from Bengaluru, says that when his father got hospitalised three years ago, he had to pay a hospital bill of Rs 150,000. The health insurer reimbursed the money later but after a deduction of Rs 40,000, citing preexisting disease ( PED). Amit blames his lack of awareness for accepting this illegal deduction.

Many, like Kumar, face similar problems across the country, despite the regulator framing clear guidelines on risk coverage with waiting period or exclusions.

As per the Insurance Regulatory and Development Authority of

India ( Irdai) norms, a preexisting disease means any condition that is/ are diagnosed by a physician within 48 months prior to the effective date of the policy issued/ reinstated by the insurer, or for which medical advice is recommended by a physician within 48 months prior to the effective date of the policy or its reinstatement.

However, insurers are reluctant to provide health cover for those suffering from PEDs. They rather advise subscribers to enroll for a health insurance policy early in life, as health issues develop as one ages.

"Health insurance proposals are underwritten based on the health parameters and the health status of individuals. Proposals with highly adverse health status or serious health conditions are commonly not accepted due to underlying high risk. As per the Irdai guidelines, the PED definition is standardised. However, underwriting guidelines are decided by the respective insurance company within the framework of health regulations," said Dr Rashmi Nandargi, head- health retail underwriting, Bajaj Allianz General Insurance.

"In many countries, health insurance is provided by the government and private insurance is opted over and above the mandatory insurance provided by the government. However, wherever private insurance is prevalent, underwriting guidelines are decided by the insurer." Nandargi pointed out.

In fact, the condition on

PEDs is another grey area where people have to face difficulties while buying a policy or at the time of claim settlement. Insurers are putting the lives of sick and disabled at risk even during the Covid19 pandemic through claim denials and obfuscations. There are many instances where policy- holders' grievances are either ignored or not even being heard by the regulator.

Abishek Muthian, a start- up coach from Coimbatore, says the Irdai's grievances cell is biased towards insurers and doesn't really do anything when it comes to policy rejections. He was denied a top- up on his basic policy when he needed it most, despite knocking at Irdai's doors.