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Mid of policy period change

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16 Feb, 2022 by  ashok T

Hi,

I have policy for my mother with star health since april 2020. I renewed it during april 2021 as well. While initially purchase of policy i delcared all the PED for my mother(bp, diabetes, thyroid, heart attack, angio report) and also all her surgeries(uterus removal, gall bladder removal) till date date of april 2020. all was going good with respect to insurance till nov 2021. Nov 2021 my mother developed severe knee pain first time in her life(she is 63 years old) and she got admitted in hospital for the same. We went for cashless claim and claim got settled as per insurance policy. But after claim is settled they added two endorsement into my policy, one is permanent exclusion for sarcoidosis and other one is pre existing disease for gastro intestinal. I got automated email by jan 2022 but they got added in nov 2021 itself without any notification. Then from jan 2022 i am following up with star health different teams like customer care, renewals, grievances etc. Only team responded is renewals team, all they are saying is it got added after claims settlement based on our doctors opinion nothing else they are saying.


My two questions are simple as below but i am not getting any response appropriately and moreover guy from grievance blocked me in whatsapp after multiple follow up. Please help me understand what should i do ? is it fair for insurance company to not provide valid response for my query or am i expecting too much and its not fair to ask them for explanation ? if its fair and i am not getting response, will there is any other way i might get this issue resolved(if you guys thing issue in their end based on my explanation of issue)


First question i asked the star health is as follow, "star health added permanent exclusion for sarcoidosis to my mother policy during the middle of the policy period and I don’t even know that medical disease name. I have been paying for my mother's medical care for more than 14 years, if she has that sarcoidosis disease then how would I not be aware of that information or how would i not declare the information about sarcoidosis if she had already had when i declared all the bunch of pre existing diseases like bp, sugar, heart attack, surgeires etc while purchasing the policy by april 2020 ? They added Sarcoidosis as new permanent exclusion during mid of policy period without even talking to me or asking me. Even if its fair for them to add something without asking me which i agree as well, atleast when i am asking to explain the valid reason for adding sarcoidosis they should provide me detailed explanation on what basis they added that as permanent exclusion during mid of policy period right ? As a policy owner of my mother, i think i have rights to ask the explanation for this but all i was informed was based on recent claim processing for your mother we added it. But i asked them, See recent claim is for my mother leg pain issue and that too she started complaining about leg issue for first time by novemember 2021 in her life time which is 20 months after the policy inception date and she never had leg issue when we purchased the policy and she got admitted for leg issue so the claim got generated. I would like star health to answer me, does the aged people will not develop new health issues as they get older ? I have purchased policy by april 2020 and i renewed once in april 2021 and my mom developed leg issue for first by november 2021, so whenver we go for claim for new illness if they add permanent exclusion or anything into policy like this then what protection we have as policy holder who declare all the PED during policy inception thinking all will go smooth from now or after 36 months of waiting period with respect to claim settlements ? I said to star health that you have to explain to me why you added Sarcoidosis as permanent exlcusion with detailed response so i can understand why policy got changed. It is totally a mistake in their end to add something into policy for the disease which my mom never had during policy inception date for sure. Still I don’t know what sarcoidosis is till date and how it is related to my mother. Even if its related to my mother after recent claim then that claim happened after 20 months of policy inception date which i dont know how it can qualify for permanent exclusion. I asked them to show me a proof and also explain to me why you added it.First my mom never had sarcoidosis during the policy inception date or till now. For discussion sake let's say even If she developed sarcoidosis or any other disease after policy inception date of 20 months, is that fair to add as permanent exclusion or pre existing after 20 months of policy inception ? Then what is the use to buy policy by declaring everything upfront for all PED's and star health keep adding new PED and permanent exclusion whenever claims come.After close to 50 days i got no proper response or valid reason why my policy got changed. It added so much stress on me because of them.


Second question, Star health added one new pre-existing disease for gastro intestinal. I declared all pre existing while buying the policy including all the surgeries she underwent till date by april 2020. I asked star health then how come you can add in the middle of the policy period new pre-existing disease for gastro intestinal and just tell me it won’t be covered for the next three years from nov 2021 date ? If you missed adding it during policy inception date then you have to add it and the back date to the first date of my policy purchase and not from nov 2021 date. Explain to me why you added that new pre-existing disease for gastro intestinal now first of all when I declared everything upfront during the initial time of policy purchase ? Same like first issue, i never got response for this issue as well.


I said I need an explanation for my above two questions for the past many days to star health and multiple follow up's during my mid night because i live in abroad, I lost many night of sleeps just to get hold of someone but nothing helped till date. So i am reaching out to your help and i sincerely request to look into my issue please. I am not sure if common people should go through issues like then when a company does not have transparency with the business they run even after i delacred all the pre existing for my mother. Even now i am saying if they explain valid reason in detailed response which i can understand then i am totally fine with whatever they modifed but that never happened so far from them.

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1 Answer

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21 Feb, 2022
Mahavir Chopra
Founder, Beshak

Hello Ashok,


Here is my take on your questions:


As per Health Insurance Regulations, Insurers can add a permanent exclusion in the policy only after the policyholder's consent. This permanent exclusion is hence not in compliance with regulations.


Adding an additional pre-existing exclusion

Adding an additional pre-existing exclusion after claims can only be done if the insurer has observed that this pre-existing disease was not disclosed at the time of buying the policy for the first time, or making an upgrade in the policy coverage. They also need to issue a letter communicating the addition of such a new clause.


What you should do:

  1. You need to carefully check the hospital papers, especially the initial investigation done by the treating doctor and his team - whether there is any mention of these two diseases in the papers. Sometimes doctors make wrong notings, and that could be the reason you are going through this ordeal.
  2. If everything is clear, you need to follow the grievance process including posting complaints on IRDAI's IGMS portal. IRDA - IGMS Complaint Logging (policyholder.gov.in)
  3. You can also contact Insurance Samadhan - They are paid service for such grievances.



Hope this helps.


Regards,

Mahavir


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