Regarding Health Insurance Moratorium Period & Portability

Hi Shailesh Sir,

Thanks for your answers. Can you guide on tue below as well:-

1) What is fraud not related to non disclosure?

2) After 8 year moratorium period is over, can insurance company say that you were taking these medicines before the policy, however, while buying the policy, you did not disclose so the claim is rejected. Hope non disclosure and misrepresentation does not fall under fraud.

3) Also, if their is special exclusion in the policy, then it is compulsory for insurance company to mention it in policy document?

4) Suppose I have 10 lack of base policy and 50 lakh of super top with 5 lakh deductible from another company, in case of claim, before hospitalization I know that the expenses will be around 7 lakh which will be covered in base policy, however, during hospitalization some complication happened and the estimated claim is more than the base policy amount then can we inform super top policy company, will they not accept the claim as we did not inform them during intial days of hospitalization.

5) Also, in case we are claiming from base policy and we know that claim amount will not exceed the insured amount of base policy, still we need to inform super top up policy company during hospitalization?

6) Hope having base insurance from one company and having super top up policy from another company is completely fine?

7) Can multiple policies of different family members be linked to same mobile and email? Hope in irda website claim information is not linked with phone and email and is only linked with aadhar or policy number.

8)Also, a case where our family is not aware about our insurance details and something happens to us like accidents and we are unconscious and we are hospitalized. Our family is not aware of insurance policy so they dont inform the insurance company with 24 hours of hospitalization, can reimbursement be taken later on? Asking this question becz in policy document its is written planned hospitalization to be informed in 48 hours and 24 hours in emergency otherwise claim will not be accepted.

Dear Raghav

Thanks for your questions, answers given below :

1. Fraud means , escalated bills and wrong medical bills .

2. Post moratorium, claims can not be repudiated on the basis of non disclosure.

3. Yes , these are standard exclusions as part of the contract .

4. No , you can approach super Top up any time during treatment . Let us say your expense is rs 20 lakh then super Top up company would pay rs 15 lakh after deductible of Rs 5 lakh .

5. No need to inform but for safety , keep them updated so that they have medical records .

6. Yes , both are independent contracts and mutually exclusive.

7. Yes , it can be linked to same mobile and email .

8. Yes , it can be intimated as soon as you come to know provided you have right logic to explain . Insurance company can not deny .

Hope this suffice

Shailesh

Insurance Samadhan

Shailesh sir need your help,my parents had a national insurance policy since 2002, Sum insured was of 3lac each+1.5lac bonus till year 2019.In year 2020 sum insured was increased to 5lakhs +1.5 lakhs was bonus.So in totality 19years with national insurance.

Now in 2021 we decided to port it to Niva Bupa insurance and sum insured was 6.5lacs as previous policy was of 5lakhs+1.5lakhs.

Will we be covered in moratorium period.If yes than for what sum insured will we be covered/applied by moratorium clause.

Can niva bupa company reject claim by applying any waiting period or PED (which was never there).

We had not made any claim in national insurance our history was crystal clear with no claims made.

Will any non disclosure clause be applicable which nivabupa company is trying to force on us after porting/moratorium completion in previous company.

Niva bupa Company is stating moratorium is given only if in same company we complete 8 years.Is it correct statement.Sir is it possible for you to share IRDA guidelines or clause which can help us in fighting our battle with insurance company.

Please guide it will be great help

Thank you.

Regards,

Umesh

Hello Umesh.

Will we be covered in moratorium period.If yes than for what sum insured will we be covered/applied by moratorium clause.

In my view, in the absence of any specific regulation in this regard, the insurer will enforce a moratorium from the time they have issued the policy. The portability period may not be taken into regard. By spirit, of course, moratorium should include portability, but for this, you may have to go to the court and get this enforced. IRDAI clarification is overdue on this.

Can niva bupa company reject claim by applying any waiting period or PED (which was never there).

No insurer can reject a claim for PED if it did not exist. However hope you have made the right declarations during portability, including informing the insurer of any new disease after the old policy National was issued. Insurers have in the past rejected claims for any omitted diseases that have occurred during the old policy period (in your case the 19 years of National cover)

Thank you for your reply.

I had seen Shailesh Kumar Sir reply https://www.beshak.org/forum/post/moratorium-period-in-case-of-portability/

It has different opinion.

Also on turtlemint it has different perspective on similar topic

https://www.turtlemint.com/health-insurance/articles/irdai-says-health-insurance-claims-not-contestable-after-8-year-of-premium-payment/

Which opinion is correct ?

When I spoke to sales team of niva bupa today just to see their knowledge ,They say moratorium will be carried forward.They say moratorium will be applied on same old sum insured which has completed 8 years and if we increase sum insured ,then on that increased amount moratorium will not be applied.