Avoid getting Trashed

The most critical moment in the entire tenure of an insurance policy is when a claim is filed. “Rejection, of any kind hurts.”In an insurance claim, the blow is multitudinal – financial, emotional,  physical - thus making it more stressful.

“One of the most common queries we get from people buying a policy is whether the insurance company will honour the claim,” says Rahul Agarwal, founder, Ideal Insurance Brokers (P) ltd., a reputed insurance brokerhouse across the country.

I was diagnosed with vertigo, a type of dizziness, this May. This is not all. The real trouble started after three days of hospitalisation when the TPA of my health insurer deprived me of the cashless claim facility. Though the insurance policy had promised me cashless hospitalisation, I had to pay the bill of Rs. 39,000 from my own pocket.

The TPA refused on absurd grounds like the illness could have been due to some pre-existing ailments and that they needed time to scrutinize the claim. However, when I referred to medical professionals, they told me that my illness had nothing to do with my cardiac ailment which was declared as pre-existing in my health Insurance policy.

While the denial of the cashless facility didn’t necessarily mean repudiation of the claim, it did shake my confidence in the insurance company. I, who has been paying around Rs 18,000 every year since 2009 as premium to the Health Insurance Co., felt cheated.

The figures of claims rejected/ pending as of today would definitely make any policyholder dubious about the efficiency of his insurance cover. But this is only half the picture. The no. of claims settled is no less. The stringent procedure followed to settle Insurance claims is to ensure that only genuine claims are paid. In fact, if Insurance companies show leniency and keep accepting bogus claims, it may cost customers more in the form of higher premiums. It is thus the duty of the policyholder to follow all policies and procedures given in the insurance document and not give the insurer any chance to reject his claim – health or otherwise.

Here, I list some broad reasons why our insurance claims may be rejected and ways to steer clear of them –

Reason:	Solution:
NON-DISCLOSURE, partial  disclosures and wrong disclosures of significant facts such as age, nature of occupation, income, existing insurance policies, major ailments or pre-existing medical conditions.	Full Disclosure. When applying for the product, understand the consequences of concealing or giving incorrect information.
LACK OF KNOWLEDGE regarding covers and exclusions under the policy. We are not even aware when breaching a condition mentioned in the policy document.	Go through the policy terms and conditions and understand them well before purchasing. When in doubt, seek clarifications from the advisor.
DISCREPANCY IN PROPOSAL FORM because we often refrain from filling our forms and depend on third parties. They are often not aware of details and an imp fact might be inaccuratly represented.	Fill up the proposal form yourself. Submit genuine documents in an orderly and timely manner to the insurance company with details. If any discrepancy is found in the policy, immediately get it rectified.
SURPLUS EXPENSES. Private hospitals, in their quest to generate maximum revenue, sometimes perform medical procedure which may not be necessary. In motor, usually bills are blown out of proportion. These irregularities, when caught by the insurer, results in rejection of the claim.	Avoid extra costs. Make sure the medical process undergone was necessary. Do not include motor repair charges of pre-existing damages or costs not covered under the policy in the claim.