Mediclaim policy - Husband has not mentioned his high bp
8 months ago
Husband has not mentioned his high bp during his mediclaim which he has made 2 yrs ago.Now he has had a knee surgery and is claiming an amount from the insurance company.Hospital documents have revealed he has high bp since 6 yrs. will the claim b rejected or will it b approved
A.Dear Client,
Pre Existing Diseases (PED) are covered after completion of a lock-in period that varies depending upon the nature and category of diseases from 24 months to 48 months from the inception of the Health Insurance Policy that is renewed continuously for the lock-in period and thereafter. The authenticity and veracity of the hospital report need to be challenged first if the claim against knee surgery is repudiated on the ground of concealment of PED of high BP at the time of inception of the Policy by the Policyholder. So, in case of repudiation of the claim by the Insurance Company on the said ground, Policyholder needs to escalate the grievance against the arbitrary and unjustified repudiation of the claim before the Grievance Cell of the Insurer and in case the matter is not resolved then you may file a complaint the Insurer and TPA before the Dist. Consumer Commission under Consumer Protection Act, 2019 for deficiency in service and unfair trade practice claiming the entire amount of claim admissible under the policy along with the cost of litigation and compensation for harassment and mental agony.
Pre Existing Diseases (PED) are covered after completion of a lock-in period that varies depending upon the nature and category of diseases from 24 months to 48 months from the inception of the Health Insurance Policy that is renewed continuously for the lock-in period and thereafter. The authenticity and veracity of the hospital report need to be challenged first if the claim against knee surgery is repudiated on the ground of concealment of PED of high BP at the time of inception of the Policy by the Policyholder. So, in case of repudiation of the claim by the Insurance Company on the said ground, Policyholder needs to escalate the grievance against the arbitrary and unjustified repudiation of the claim before the Grievance Cell of the Insurer and in case the matter is not resolved then you may file a complaint the Insurer and TPA before the Dist. Consumer Commission under Consumer Protection Act, 2019 for deficiency in service and unfair trade practice claiming the entire amount of claim admissible under the policy along with the cost of litigation and compensation for harassment and mental agony.
Helpful
Helpful
Share
A.Dear client,
Not declaring pre-existing medical conditions will not only lead to claim rejection, but the policy will also be considered null and void.
Not declaring pre-existing medical conditions will not only lead to claim rejection, but the policy will also be considered null and void.
Helpful
Helpful
Share
Read Related Answers
Regarding insurance claim rejection
Dear client, withour directly resorting to the complaint on the insurance company try to re-inititate the claim process and talk to them and submit the required documents. Even then if there is no cla...
Hospital avoiding cashless treatment
Dear Client,
In the given situation, bring the matter to the notice of the Grievance Cell of the concerned Insurance Company endorsing a copy to the insurance regulatory authority, IRDIA. In case, no...
Medical Insurance cancelled after 3 years
Dear Client,
Pre-existing diseases (PED) are mostly expensive to treat as they are chronic in nature. Unfortunately, most health insurance plans cover pre-existing diseases after a waiting period of 2...
Legal Liability for Helper Covered If Death occurs by Gun Firing
Dear Sir,
The copy of FIR and terms of life insurance policy are to be read minutely to answer your question.
Review of award by Insurance Ombudsman
Dear Sir,
You may approach Consumer Forum or High Court for getting justice in many cases same formula being used.
Read Blogs on Insurance
Insurance Lawyers
Find Lawyers by Location
