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Corona Kavach claim reupdiation citing onset during the 15 days waiting period

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17 May, 2021 by  Avinash Sonee

One of my customers has taken a Corona Kavach policy (from Star Health) which was valid from 24/07/2020 to 05/05/2021 for 5 lakhs.


On 09/08/2020, he's got admitted in a hospital at Hyderabad with complaints of SOB, cough, fever, etc. since 4 days. He's first consulted a doctor in his town for cough and fever. The actual Covid-19 positive report is of 10/08/2020.


The company has rejected the hospitalization claim citing that

'It is observed from the consultation report dated 04/08/2020 and investigation report dated 04/08/2020, the onset of the above disease is during the first 15 days from the date of commencement of the policy.'


Can this repudiation be contested? Please advise.

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Health Insurance
COVID19

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18 May, 2021

Hey Avinash,


It is a valid repudiation. Kavach has a mandatory 15 days waiting period, so any symptoms that start during this period or any admission for Covid that happens during this period, is not claimable.


Anuj

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18 May, 2021

Dear Avinash

Agree with comments of Anuj .

Claim will be repudiated as disease happened within 15 days .

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18 May, 2021
Avinash Sonee

Thank you for confirmation.

Customer still wants to contest the claim saying that the fever since 3-4 days may not have been covid.

I've asked him to approach legally if wants to contest after approaching the grievance cell and the ombusdman.


Thank you


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I do not agree with Anuj and Shailesh. The policy mentions waiting period as under: “6. Waiting Period The Company shall not be liable to make any payment under the policy in connection with or in respect of following expenses till the expiry of waiting period mentioned below: 6.1. First Fifteen Days Waiting Period Expenses related to the treatment of Covid within 15 days from the policy commencement date shall be excluded.” Definition of waiting period is as under: “Waiting Period means a period from the inception of this Policy during which Covid is not covered.” The wording of the policy says that treatment should be taken and expenses should not be incurred during the waiting period, it doesn’t talk about detection or manifestation of symptoms. The policy doesn’t say that symptoms of Covid should not be manifested within the waiting period mentioned in the policy, eventhough logically that should have been the intention of the policy. So I would think there is a solid ground for going legally against the insurer. The interpretation of the wording shall be in favour of the party who did not draft the policy, which in this case, is the insured.
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20 May, 2021
Avinash Sonee
@Hari sir, looks like I can't reply to a comment of comment. Yes, I did explain the customer that he can contest on legal grounds using this wording. I've another customer with a similar story which is in the legal process since close to 2 years now. Thank you for confirmation.
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20 May, 2021
Avinash Sonee
Also, in most of the other health insurance policies, I see a similar wording - 'Expenses related to the treatment of any illness within thirty (30) days from the first policy commencement date shall be excluded except claims arising due to an accident, provided the same are covered.' which talks only about treatment not about the 'onset of the illness'. If we compare this with a '24 months waiting period' for treatments like cataract or knee replacement, the 'onset of illness' clause doesn't hold good, right? Are there any such claims (onset within the 15/30 days waiting period) in the past which were rejected at first and then the legal system granted the judgment in favor of the customer.
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Avinash, waiting period is like a moratorium period during which claim won’t be entertained. There is no proviso that the onset of illness should not have happened during the waiting period. That’s the case with all health insurance policies unless otherwise specified. Even in Arogya Sanjeevani Policy also it is the same.
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20 Jun, 2021
Avinash Sonee
I'd like to update you that the claim has been settled for 5 lakhs (full SI). Thank you @Hari sir for your reinforcement and Beshak for the platform.
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