INSUBCONTINENT EXCLUSIVE:
MUMBAI: Non-disclosure of existing health conditions is the main reason for insurers to reject claims
Around 25% of health insurance claims are rejected because the insured had pre-existing conditions like diabetes or hypertension, which were
not disclosed at the time of purchase
Another 25% of claims rejections are because policyholders were unaware of the terms of cover and claimed for OPD(outpatient department) or
other treatment excluded under the policy.A large chunk of claims (16%) are rejected because the claimant did not revert to
queries.PolicyBazaar, which has an insurance broking licence, analysed the data on two lakh health insurance claims between April to
September 2023, of which 30,000 were rejected.From the insured's perspective, the worst damage to their financials is caused by claims
rejected for non-disclosure
While an equal number of claims are turned down for being outside the scope of the policy, these are low-value claims, with the occasional
claim being turned down for experimental procedures."While rejections due to the treatment being outside the scope of the policy are
numerous, they are usually for low-value expenses
The insured file many claims out of ignorance
We have seen OPD claims and claims for spectacles, which are, of course, not covered," said Amit Chhabra, chief business officer - health
insurance, PolicyBazaar."Claims are sometimes rejected due to the non-disclosure of material facts
While distributors may sometimes overlook or fail to ensure disclosure, the insured, as a party to the contract, bears responsibility
It is crucial for insurance buyers not to gloss over the proposal form, as the insurer may reject claims even if the non-disclosure is
unrelated to the ailment," said Segar Sampathkumar, director of health at the General Insurance Council, which represents the
industry.According to Chhabra, most rejections are due to a lack of understanding of the policy
"Non-disclosure affects even those claims that are unrelated to the pre-existing condition
The biggest giveaway is the initial report that the doctor prepares on admission
During admission, the insured has no choice but to declare all existing conditions as the course of treatment depends on it," said Chhabra
Insurance laws mandate that the insured disclose all facts that are material to the insurer's decision to accept the proposal
So, even if non-disclosure is not material to the cause of hospitalisation, the insured can reject the claim
