You can challenge the rejection of a health insurance claim

Reports from the pre-issuance medical test and doctors’ consultation are expected to identify pre-existing ailments


iStockPhoto
iStockPhoto

My mother, 52, has been diabetic for the past 5-6 years. She has a family floater health insurance and I am the sponsor. Her condition was declared at the time of buying the plan.

In the policy’s third year, she underwent a surgery linked to a sinusitis infection. The doctor had then inadvertently mentioned the history of chronic obstructive pulmonary disease (COPD) while referring to instances of common cold. The insurer used this information as basis for rejecting my claim. How can I fight with the insurer to get my claim?

—Vidyabhushan J. Upadhye

It seems that your insurer has assumed COPD as a reason for sinusitis infection and classified it as a pre-existing illness. Since the waiting period for pre-existing disease may not have lapsed, the insurer rejected the claim. You could take three approaches to get your claim.

First, get the treating doctor to certify that COPD was mentioned by error and the patient does not suffer from this disease. Alternatively, he could certify that the surgery was necessitated due to adverse development of acute sinusitis and COPD was not linked to this surgery.

Second, get a diagnosis done for COPD. This would medically establish the absence of COPD.

Third, if your mother underwent a medical check-up at the time of policy issuance, you could use it to present your case to the insurer. Reports from the pre-issuance medical test and doctors’ consultation are expected to identify such ailments. Prima facie, there is little motivation for an insured to suppress COPD, when she is declaring a health hazard such as diabetes.

Your case will require a holistic assessment. Since the documented information is adverse, it is likely for your claim to get rejected through the usual channel. Identify a senior person in the claims team of the insurer and write directly to that person.

If a friend takes my car out for a drive and meets with an accident, will my insurance policy hold valid? What documents will be needed?

—Jonathan Samuels

Yes. Your insurance policy will be valid as long as your friend holds a valid driving licence. However, your personal car cannot be used for commercial and unlawful purposes. The documents that will be required in this case, will be similar to the situation when you would have been driving the vehicle: a valid driver’s licence, registration certificate, surveyor report, original motor garage bills as well as receipts.

Would my home insurance also cover damages that have taken place due to a natural calamity?

—Reema Bakshi

Yes. Standard fire insurance policy issued for home insurance covers natural calamity. Calamities such as storm and flood are covered by default in standard fire insurance unless it is specifically excluded. You can also get earthquake covered as an add-on in the same policy.

Queries and views at mintmoney@livemint.com

READ MORE