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'Insurer did not increase sum assured to Rs 10 lakh'

By SANJIB JHA
June 10, 2022 10:27 IST
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Sanjib Jha, CEO, Coverfox Insurance Broking, answers your health insurance related queries.

Insurance guru

Illustration: Dominic Xavier/Rediff.com

Please mail your queries to getahead@rediff.co.in with the subject line 'Ask Sanjib' and he will answer all your health insurance queries.

 

THANGAVELU: My family is covered under Ex-serviceman Contributory Health Services (ECHS). She is having health insurance coverage from three other insurance entities. Still continuing. So, there was no pre-existing conditions.

Two and half years back, we have opted for claim re-imbursement only for blood transfusions during the pre-diagnosis period.

Later, her medical condition was diagnosed and the same was falling under IRDA exclusions. She was treated once in-patient and afterwards as outpatient. All claims for admission and medicine re-imbursement were availed from ECHS. (Once I have opted for enhancement of insurance coverage from one insurer and the TPA has refused under these clauses).

Now, after two and half years, she has recovered better (Even Doctor's perception). But she is continuing medicine with lessor dosage. Presently, her condition is fine.

My questions are:

1. Can I avail insurance facilities from insurance companies for the same issue in future? 
2. Can I avail insurance facilities from the insurance companies, for other issues than the specifically excluded?
3. Can I prefer ECHS for any eventualities for the specified issue to the extent admitted, and remaining expenditure from other insurance companies?

Please guide.

Sanjib Jha: Hi Thangavelu, good to know that your wife is doing better. Coming to your questions, yes you can avail the insurance facilities for the same ailment in future from your existing insurance companies. However, if you purchase a new insurance policy from another company, then whether you get the coverage or not will depend on the ailment and the insurer.

For other ailments, at the time of issuance an insurer analyses the risks, given the ailment of the insured. Accordingly, the insurer takes a decision whether the policy can be issued or not, there are few insurers in the market that will keep the pre-existing diseases excluded or will have a waiting period for it. However, if your ailments have developed after the policy issuance then you can avail insurance facilities for those ailments.

Answering your third question, yes you can prefer ECHS for this specific issues and the remaining expenditure can be claimed from other insurers.

Gaurang Trivedi: Why TPAs resist in reimbursing genuine expenditure incurred on ayurvedic treatment {all conditions fulfilled including admission in ayurvedic hospital}. All proofs submitted.

Sanjib Jha: Hi Gaurang, TPAs have a cashless tie-up with the insurer and if the claim is as per the policy coverage, then the claim will be entertained by the insurer. If this is not happening, given that all submitted documents and requirements are as per the policy, then you can raise this issue with the insurer’s grievance authority or their organisational ombudsman.

Rajesh Patil: I am trying to cover 34 orphan kids with mediclaim. Can you please let me know if there is any possibility to cover them through the cheapest insurance? The age group is 6 to 18 years.

Sanjb Jha: Hi Rajesh, my advice will be to decide upon a coverage value that you feel will be enough for these children. That will help you to see what premiums the insurers are offering you to fit that coverage value.

Premiums are decided through a scientific approach, a formula.

Each premium is designed in a manner that it will reflect the risk profile of an individual and accordingly a premium quote is generated. So there is no cheap or expensive insurance, it totally depends on the risk profiling of the individual and the sum insured that is suitable for an individual.

I advise you to check and compare pricing for a decided sum insured on our broking website, www.coverfox.com, which will help you see the differences in pricing and other facilities of various insurers and purchase the one that fits your requirements.

R N Mittra: I am 73 (DOB 10-07-1949). I had an open-heart surgery in Sept, 1999.

I have an Oriental Insurance Co. health insurance family floater for self and wife for 5L. They did not increase the amount to 10L. I am looking for only self or family floater Health Insurance for 5L OR TOP UP for 5L. Please advise if possible and to contact which Co.

Sanjb Jha: Hi Mr. Mittra, your existing insurer will not increase the coverage to Rs 10L given your risk profile. In this case, you can purchase a new policy from another insurer that will provide you with an additional sum insured. However, few insurers will assess your risk profile and accordingly provide you with issuance and there are few insurers who will easily provide you with the required coverage keeping the pre-existing diseases in the exclusion list.

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SANJIB JHA