While applying for a health insurance policy, the policyholder is required to fill in the application form and provide information on any pre-existing illness. Usually, policyholders tend to rely on agents to find the best health insurance plans and fill in the forms, and this is a decision that can prove to be a costly one, at a later point.
The declaration which is listed on the health care insurance proposal form of the health insurance plan is the basis on which insurers underwrite policies. They evaluate the risk and calculate the premium to be paid by the policyholder to cover that risk. When a policyholder signs the policy document, they are declaring that they have understood the health care insurance proposal inclusions, exclusions and other terms and conditions of the health insurance plan. Later, if the policyholder claims that the policy was wrongly sold to them, it would be difficult to prove this to an insurance ombudsman or a consumer court.
Rejection of Claims against Health Care Insurance Proposal
Hiding the Medical History:
When the time comes to reap the benefits of the health insurance policy, if the policyholder has hidden any facts from the insurer, they run the risk of their claim being rejected. There have been cases of applicants hiding their medical history, so as to get a better coverage for lower premium or avoid the waiting period required for pre-existing diseases.
When the insurer gets a claim, they carefully scrutinize the bills, medical procedures done and doctor’s reports, and if they come to learn of a pre-existing disease, then those could be sufficient grounds for rejecting the health insurance claim. Though you might think that the insurer is not likely to find out about any pre-existing diseases, at the time of an emergency, the surgeries performed, medicines prescribed and daily hospital notes accurately capture the patient’s medical background. The insurer would thus have to pay the entire bill out of their own pocket – a situation that can be avoided by fully disclosing one’s medical history in the health care insurance proposal.
Health insurance requires a waiting period, in the case of specific illnesses or pre-existing diseases. This waiting period might be anything between 2-4 years, depending on the type of disease. After the waiting period is completed, these diseases would be covered under the health insurance plan.
Coverage provided by an insurer is based on the information given in the health insurance policy document. Thus, any disparity between the facts while filing a health care insurance proposal, and the declaration on the policy document can lead to a rejection. Read More About Waiting Period I Health Insurance
Parameters used by insurers to assess applications:
There are some crucial columns in the health care insurance proposal form, which insurers evaluate while determining the premium amount. They are as follows:
Medical History :
Medical history implies longevity, where insurers consider the long-term costs of financing the health care of the applicant in question. If there is a history of illness, the premium might go up, and worst case scenario, he may not be eligible for the top health insurance plan.
Family History :
Insurers also take into account, the family medical history, as some illnesses could be hereditary. In those cases where both parents are suffering from the same disease, the probability of it impacting the applicant, and hindering him from availing the best health insurance is considered to be higher.
Insurers could take into account, personal habits, like whether an individual is a chronic smoker or drinker. The amount charged to such individuals, depends on the frequency, quantity consumed and type of addiction.
Insurers also consider income to evaluate risks in payment defaults. People with a stable job are more likely to qualify for the top health insurance plans in the market today, as they are less likely to miss premium payments. Though freelancers or business owners, who work on a contractual basis, their human life value is calculated on the basis of their annual turnover.
Occupation is a parameter used to gauge risk of accidents and wellness. For example, people in sedentary desk-jobs are at a higher risk as they are prone to contracting cardiovascular diseases.
It might seem unlikely that education could possibly play a part in determining whether one qualifies for the best health insurance in the market, or not. However, one’s level of education is an important criteria for consideration, as it implies a higher knowledge of the risks of a bad lifestyle, and a greater awareness about health-related matters.
How to ensure that your claim is not rejected:
- Fill correct information in your form while buying a health insurance plan
- Take time out to understand the health insurance plan wordings and its complications
- Be aware of the policy sub-limits, exclusions and terms and conditions
- Go for the medical check-up while applying for a policy, if needed by the insurer
- Provide full disclosure of your health-related information to avoid claim rejection at a later stage
- Fill in the information correctly and provide the proofs needed, while filing a claim
- Ensure that your policy doesn’t lapse, and that you pay premiums on time
- Evaluate the clauses contained in waiting period, critical illness plans and family floater policies
- Ensure that you have bought adequate coverage while considering your present needs and future risks to get the top health insurance.