If you are stuck in such a situation, here is what to do.

Mr. Alok, a 30-year-old IT professional from the city of Anandpur, faced a significant health challenge a few years ago when he was diagnosed with a cardiac condition. After a successful recovery, he is now leading a healthy and active life. Wanting to secure his family’s financial future against medical emergencies, he applied for a comprehensive health insurance policy from “OmniCare Health Solutions,” a leading insurer. To his dismay, his application was rejected, citing his past medical history as a “pre-existing disease” (PED) that posed a high risk. Mr. Alok felt helpless and wondered if there was any legal recourse available to him or if a past illness meant he could never get health insurance coverage.

Advice in such cases

Facing rejection for health insurance due to a pre-existing condition can be disheartening. However, it is not the end of the road. Here is some practical advice:

• Full and Honest Disclosure: Always disclose all your medical conditions truthfully and completely in the proposal form. Hiding a pre-existing disease can lead to the cancellation of your policy and rejection of claims later, citing non-disclosure.
• Understand Waiting Periods: As per regulations, insurance companies are required to cover pre-existing diseases after a specific waiting period, which can be up to 48 months. Once this period is over, the insurer cannot reject a claim related to that condition.
• Look for Specialized Policies: Some insurance companies offer specific plans designed for individuals with pre-existing conditions. These may come with higher premiums or co-payment clauses, but they provide crucial coverage.
• Read the Policy Document Carefully: Before purchasing any policy, thoroughly read the terms, conditions, inclusions, and exclusions. Pay close attention to the definition of a pre-existing disease and the associated waiting period.
• Consult with Lawyer: The very basic and important step to start is talk to Lawyer / advocate. You should not hesitate in paying his consultation fee i.e. might be in range of Rs. 10,000 to 50,000 depends case to case. He is helping you in this situation of come out. He is expert in the domain and can help you explain the procedure which you might have never explored. A good lawyer can get the issues resolved much faster than you think.

Applicable Sections of Law

The health insurance sector in India is primarily governed by the Insurance Regulatory and Development Authority of India (IRDAI). There is no specific section of the Bharatiya Nyaya Sanhita (BNS) that applies here, as this is a civil and regulatory matter, not a criminal one.

• IRDAI (Health Insurance) Regulations: These regulations are paramount. They define a “Pre-Existing Disease” and mandate that every insurer must cover PEDs after a maximum waiting period of 48 months. An insurer cannot permanently exclude a PED.
• Principle of Uberrimae Fidei (Utmost Good Faith): This is a fundamental principle of insurance contracts. It requires the person seeking insurance to voluntarily disclose all material facts relevant to the risk. The insurer’s decision to accept the proposal and set the premium is based on this information.
• Consumer Protection Act, 2019: If an insurance company engages in unfair trade practices, such as arbitrarily rejecting a claim after the waiting period or misleading a policyholder, you can file a complaint in the appropriate Consumer Disputes Redressal Commission.

If you are the complainant

If your insurance application is unfairly rejected or a claim is denied, you are the complainant. You should follow a structured approach to seek redressal:

• Consult with Lawyer: The very basic and important step to start is talk to Lawyer / advocate. You should not hesitate in paying his consultation fee i.e. might be in range of Rs. 10,000 to 50,000 depends case to case. He is helping you in this situation of come out. He is expert in the domain and can help you explain the procedure which you might have never explored. A good lawyer can get the issues resolved much faster than you think.
• Grievance Redressal Officer (GRO) of the Insurer: The first step is to formally write to the designated GRO of the insurance company, outlining your complaint with all supporting documents. They are obligated to respond within 15 days.
• IRDAI Grievance Redressal Cell: If you do not receive a satisfactory response from the GRO, you can escalate the matter to the IRDAI’s Integrated Grievance Management System (IGMS), which is an online portal for policyholders to register complaints.
• Insurance Ombudsman: This is a quasi-judicial body that resolves disputes between an insurer and a policyholder. The Ombudsman’s decision is binding on the insurance company if the policyholder accepts it. This is an efficient and cost-effective method of dispute resolution.
• Consumer Court: If all else fails, you can file a case in the Consumer Court for deficiency in service or unfair trade practices.

If you are the victim

If you feel victimized by an insurer’s decision, it is crucial to act methodically and not emotionally. Your goal is to prove that the company’s action was arbitrary, unfair, or against the regulations.

• Consult with Lawyer: The very basic and important step to start is talk to Lawyer / advocate. You should not hesitate in paying his consultation fee i.e. might be in range of Rs. 10,000 to 50,000 depends case to case. He is helping you in this situation of come out. He is expert in the domain and can help you explain the procedure which you might have never explored. A good lawyer can get the issues resolved much faster than you think.
• Preserve All Communication: Keep a record of every interaction with the insurance company, including the proposal form, emails, letters, and notes from phone calls.
• Obtain Reason in Writing: Always insist that the insurance company provide the reason for rejecting your application or claim in writing. A vague rejection can be challenged.
• Review the Rejection Against Regulations: Analyze the reason for rejection. Does it violate any IRDAI guidelines? For example, was your claim for a PED denied even after the completion of the waiting period?

How the police behave in such cases

The police have no role to play in disputes related to health insurance applications or claim settlements. These are contractual and civil matters. Police intervention would only be warranted if there were elements of a criminal offense like forgery of documents, impersonation, or organized fraud, which is not the case in typical disputes over pre-existing conditions. You should not approach the police for such issues; instead, you must use the grievance redressal channels mentioned above.

FAQs people normally have

• Can an insurer refuse to sell me a policy because I have a PED?
  
  Yes, an insurer has the right to assess the risk (underwriting) and may decline a proposal if the risk is deemed too high. However, they cannot have a blanket policy of refusing everyone with a certain condition. The decision must be based on an individual risk assessment.
• What if I forget to mention a minor illness I had years ago?
  
  The principle of utmost good faith requires you to disclose all material facts that could influence the insurer’s decision. Even a seemingly minor illness could be considered material. It is always better to over-disclose than to risk having your policy voided for non-disclosure.
• Is the 48-month waiting period for PEDs applicable to all policies?
  
  The 48-month period is the maximum permissible waiting period set by IRDAI. Many insurance companies offer policies with shorter waiting periods of 24 or 36 months to attract customers. You should compare policies to find one with a shorter waiting period.

What evidence is required?

To build a strong case, you need to have comprehensive documentation. The key pieces of evidence include:

• A copy of the filled and signed insurance proposal form.
• All medical records, doctor’s prescriptions, and diagnostic reports related to your pre-existing condition.
• The rejection letter or email from the insurance company clearly stating the reason for denial.
• A copy of the policy brochure or advertisement that you relied upon.
• Proof of all communication with the insurer, including emails and registered letters sent to the Grievance Redressal Officer.

How long will the investigation take?

This is not a criminal investigation but a grievance redressal process with defined timelines at each stage:

• Insurer’s Grievance Cell: The company is required to resolve the complaint within 15 days.
• Insurance Ombudsman: The process here can take anywhere from 1 to 6 months, depending on the complexity of the case and the workload of the specific Ombudsman’s office.
• Consumer Court: Legal proceedings in a Consumer Court can be more time-consuming. A case in the District Commission may take from 6 months to over a year, while appeals in State or National Commissions can take longer.

Advocate Sudhir Rao, Supreme Court of India