Recently Consumer court directed an Insurance Company to pay a rejected Health Insurance claim on the basis of Medical checkup done at the time of Health Insurance. In this case, Insurance Company has asked the insured to undergo a Medical checkup at the time of commencement of risk.
This decision is very important because one of the key reason of was non-disclosure of pre-existing diseases. It is very difficult for general claim rejection public to establish that there is no intention of non-disclosure.
Rajan took his Health Insurance in 2018. Rajan was diagnosed with Diabetes and Hypertension in 2020. In 2021, Rajan had an episode of Dengue. As his condition deteriorated, he was admitted in hospital and was marked as patient of Diabetes and Hyper Tension. He was admitted to nearest hospital and spent over ₹ 2 lakh in treatment. Claim was rejected on the basis of non disclosure of DM and HTN in 2018. Rajan tried to explain that he was diagnosed with Diabetes only in 2020 but Insurance Company refused to believe and rejected the claim.
Alok had a back injury as had fallen from Motorcycle. During operation, Alok declared that he had a back injury during his college days while playing football. Doctor mentioned this in the report and Insurance Company rejected the claim under non-disclosure.
Importance of Pre Medical Checkup in Health Insurance Policy
Such incidents are very common and most of health insurance claim rejection would fall in the category of non-disclosure. Such incidents can be avoided through steps detailed below:
- Declare all health related facts as known to you like diseases in body which has damaged body organs like Thyroid, Kidney, Liver, Heart, Pancreas, and Brain. These declarations are important because of prognosis of these diseases.
- Declare all tests undertaken by you.
- Declare all Diagnosis and not the symptoms.
- Declare if you had any episode of orthopedic problem.
- Declare Genetic or Neuro disorders which is known to you.
- Declare all medicine being taken now or taken in past.
It is easier to expect but very difficult to execute because most of the time we work with a “Chalta Hain” attitude and ignore facts.
When Insurance Company ask you for medical test:
- When sum assured is higher i.e. more than ₹ 50 lakh. Today, most insurance companies avoid Medical because of expenses involved.
- When age is more than 60. Here again, it is not commercially viable to ask for medical test.
Though company is not asking for medical test but it is in the interest of Insured to undertake a standard body check up including Lipid Profile / Fasting Blood Sugar / Thyroid Profile / Kidney Function Test / Liver Function Test. This report can be kept along with the Policy Document so that any claim rejection can be handled with data in hand.
Insurance Samadhan advises all new prospects of Health Insurance to undertake Health Checkup which is available within ₹ 2000.