What should I do if my health claim is rejected?
—M. Chourasia
An insurer has to clearly specify the reason for rejection and cite the specific clause under which the claim is rejected. In case you do not agree with the insurer’s interpretation, you can challenge it at multiple forums. Typically, my first port of call is to escalate within the company itself, i.e., to head of claims or underwriting or sales, depending on the reason for rejection. If this does not work, I will write to the grievance cell within the company. The response of the insurer’s grievance department becomes the basis of complaint with the grievance redressal cell of the consumer affairs department within the Insurance Regulatory and Development Authority of India. You can also move straight to the insurance ombudsman and thereafter to the consumer court. Generally, insurer’s grievance department and ombudsman respond well to a clear line of reasoning. Say, an insurer rejects a liver damage claim because it believes the ailment is due to alcohol abuse. If it is not, then you need to clearly establish the alternate cause, supported with medical documentation. This increases the likelihood of claim payment.
My wife underwent an abortion. Can I claim that money through my insurance?
—Parth
Most individual insurance products do not cover abortions. If the abortion is necessary to protect the mother’s life, then a case could be made to cover abortion if it is certified by a medical practitioner. Voluntary abortion is not covered.
What is the maximum number of claims allowed in a year? What are the documents required to make a claim?
—Charlie Issac
Unless your policy explicitly says so, most individual policies do not have a restriction on the number of claims in a year. The maximum utilization is limited by the sum assured. The total value of all claims should not exceed the overall sum assured in the policy. Insurers have increasingly started introducing the concept of any-one-accident limit in individual policies. This clause limits the maximum amount that can be used in any one claim. The balance sum assured can be used for other claims in the same year.
The claim documentation varies by policy type. However, the common documentation across products is intimation to insurer immediately after occurrence of the event and detailed bills and receipts for expenses incurred to make good the loss. Then, depending on the loss, additional documentation such as police first information report in case of burglary, or fire brigade report in case of a fire claim are required. On first intimation of the claim, insurers typically revert with all required documentation for that particular type of claim.
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