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Last Updated : Oct 07, 2015 12:49 PM IST | Source:

Can delayed health insurance claims be settled by insurer?

Health insurance buyer is expected to inform the insurance company within stipulated period of time. However, in genuine cases, a delay can be entertained.

Naval Goel

It was a bright sunny day on August 18 in the year 2014, Uttam was on his way to his office in Cyber City, Gurgaon. All of a sudden, he received a call from his father who informed that his mother had suffered a cardiac arrest a few minutes ago.

He went into a state of shock! Somehow, he managed to control himself and then turned back to home. Uttam took a flight to Jaipur and reached there in a span of an hour. To his dismay, his father also went into depression and had to be taken care of. Uttam did all what a son could do. On the positive side, his mother was admitted to the hospital well within time and she was treated well over there. His father too was in depression and required to be attended. His parents started recovering soon. In a span of 4-5 days, everything started getting back to normal.

But, in these difficult times, Uttam did one goof-up. He forgot to inform the health insurance service provider about this incident. His parents were duly covered under the group insurance plan his company had offered to him. He had even paid Rs 15,000 as his share towards the premium amount.

Apparently, there were some terms and conditions, every policy holder was supposed to follow. As per the policy, Uttam was expected to inform the insurer about any hospitalisation within 48 hours – that means within two days. But how much time did he took? Three days!

Was that a big mistake? Yes, according to the health insurance company. They rejected his claim in no time. The bill was running in lakhs. The company wanted to rule it out anyhow. It was a sort of loss to them. Uttam challenged their decision and proved that there were some genuine reasons due to which he could not inform them within the specified period. It was just a matter of delay of one day. But the insurer remained stiff and did not even try to consider his requests in any manner.

Uttam was upset with this approach of theirs. He was feeling exploited. Of course, anyone will. He had a right to be heard of.

After all the efforts with the company, Uttam decided to not to let it go like this. Being a well-paid executive in a BPO company, he was financially strong. He was not worried about the health care expenditure he incurred for treating his parents, but the way his case was handled by the health insurance company.

Scenario of claim settlement in health insurance sector

Numbers are for 2013-2014
*Carried forward from prior year
Source: IRDAI

After doing some discussions with his colleagues, he decided to take this matter to the Insurance Regulatory and Development Authority in India (IRDAI). He filed a complaint through online mode, and uploaded all the relevant documents such as hospital certificates, invoices, policy documents, claim repudiation letter, etc. His complaint was quickly acknowledged by the IRDAI’s portal. After a few days, he got to hear from his insurance company. Surprisingly, the company was now ready to settle his claims.

Well, it is true that every policy holder has to abide by the terms and conditions of his insurance policy document. At the same time, there are some conditions under which policy holder is given the flexibility of practicing his consumer rights.

The IRDAI has already issued formal notification to all the insurance companies in India about the subject discussed above. Under some specific conditions, an insurance company has to consider claims even if they are filed in a delayed manner. There must be reasons which are seen as not in control of the policy holder.

The policy holder has to prove that there were genuine reasons behind the delay and that it was completely unintentional. All the insurers are expected to practise a sound system of analysing cases under which claims were filed with some delay. The authority, in its notification, has clearly mentioned that if companies start repudiating claims frivolously, people will start losing confidence in the insurance industry in India.

Insurance companies have to exercise utmost care and caution while dealing with such cases and settle them on the basis on merit. At the same time, the authority has taken a strict approach towards false and bad claims.

However, to avoid such a situation, you should always carry the contact details of your insurer with you at all times along with soft copies of your policy document for instant referral in cases of emergency. If still you face a problem, approach IRDAI as they are willing to offer the best support to the consumer’s interest.
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First Published on Oct 7, 2015 12:49 pm
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