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The One Thing You Can Do - To Avoid Claim Rejections In Health Insurance With Pre-existing Disease

Team Beshak
By Team Beshak
We breathe insurance :)
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With the way healthcare and hospitalisation costs are soaring -  health insurance today is a must if we don't want our bank balance emptied at the sight of our first hospitalisation! All the more so - for people with pre-existing medical conditions - who are more likely to need hospitalisation sometime in the future. 

Insurers are aware of this higher risk in people with pre-existing diseases. And hence, when it comes to providing health insurance for them, they think twice and lay down a long list of questions to clearly understand what they’re getting into. They rely on the information you provide in the form of declarations to estimate the risk and charge a premium accordingly. So - this medical history and declarations are the very basis for the contract they make with you, the insured. 

In this article, we’ll understand why you should always provide a detailed and accurate medical history - including all your underlying health conditions. And what can go wrong if you don’t. 

Why does the insurer need my medical history?

The insurer will need details about any medical condition, disease, infection, or injury you have had in your past on the insurance form. This information is analysed to understand the risk they’re taking by providing you a cover - and the appropriate premium they should charge. Especially, if you have a preexisting condition - this information will help them helps them make crucial decisions such as - 

  • Can they afford to provide you coverage for your illnesses?
  • If yes, then how much premium should they charge you - for the risk they’re taking?

If you purposely or accidentally provide an incorrect or incomplete picture of your health, they will remain in the dark, they won’t be able to make an informed decision about how to insure you. 

So, make sure you do your homework well - medication, medical files, talking to family doctors, etc. and give accurate details to the insurer about every disease, surgery, or any major injury that you’ve had in the past - even those you had in childhood. Further, in case you suffered from COVID 19, the insurers would like to know the severity of your symptoms as well as the treatments you were given. Hence, you should provide every detail accurately.

In addition to these, make sure to answer questions related to lifestyle carefully and in detail - like smoking, drinking, or loss or gain of weight, without blindly answering them in a yes or no. 

A question you might have

What about medical tests, then? They’ll show any diseases I have. So, once I submit my medical tests to the insurer - it is their headache to decode what the tests say and make a decision accordingly. Right?

Well. Not exactly. This is a common mistake individuals make. What’s worse - we’ve even heard stories of financial advisors suggesting policy-buyers to hide certain information - so they get the policy approved quickly. But - that’s not right at all. A medical test, however comprehensive - cannot detect all the diseases and conditions you are suffering from, or have had in the past. So - the insurer will still rely on your self-declarations to make the final decision. 

Here’s what can happen when you don’t make the right declarations

In the future, if you ever get hospitalised and the medical documents/records or the doctor’s notes reveal that a specific condition was missed from informing the insurer, then the insurer can reject the claim, even if the hospitalisation was for an unrelated illness. For instance, if I have hidden information about diabetes, which is revealed at the time of a claim for say an accident - an insurer can still decline a claim, by cancelling the policy on grounds of misrepresentation. 

Remember - the health insurance policy is a deal struck between you and the insurer, who is a for-profit, probably a private organisation. The insurer is in no way obligated to give you the policy regardless of your health condition. IRDAI allows insurers to conduct their own risk evaluation before a case is accepted or rejected. And, if you have a medical history, you’re a relatively bigger risk for them to cover - and hence, they can look at you differently, add special conditions, demand a higher premium, or even reject your proposal altogether.

So, make sure you provide every detail about your medical history honestly and accurately. Do not intentionally try to hide anything. Otherwise, it makes no sense to even have a policy. You’ll keep paying premiums, until such a time when the insurer realizes that you misrepresented facts - and decides not to cover you anymore!

If that happens - 

  1. You’ll lose all the premiums you’ve paid so far - and not get anything back.
  2. Your claim will be declined - so you’ll pay your hospitalisation bills out of your pocket. 
  3. You’ll not get any other health insurance plan - as your medical history will now clearly show complications. Either other insurers will charge exorbitant costs to cover you - no plain-and-simple reject your applications.

So, you see, when you hide facts you will face problems, not the insurer. Just because buying health insurance with a medical history is difficult or expensive - it doesn’t mean it’s okay to keep the insurer in the dark. 

The One Thing You Can Do

If you don’t want the insurer to cancel your policy or decline your claim, make sure that you have done your due diligence, that is - you’ve accurately provided every medical detail you are aware of, to your insurer. You keep your end of the deal - and the insurer too, will keep their end of the deal. 

It’s that simple!

Got a question you’d like to get clarified? 

You can post it on the Beshak Insurance Forum - and get answers from vetted experts, for free!  

Key takeaways
  1. Medical history refers to any and all medical conditions from your past.
  2. It includes every illness, surgery, any major injury that you’ve had in the past.
  3. You must truthfully and accurately provide details about your medical history to the insurer. Do not try to hide anything.
  4. You should also give detailed answers to questions related to lifestyle - like smoking, drinking, or loss or gain of weight, without blindly answering them in a yes or no. 
  5. The insurer could decline your claim or cancel your policy if he finds out there has been misrepresentation on your part and you might find it difficult to get a policy elsewhere. 
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Team Beshak
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What's your Pincode?

29 Oct, 2022
by: Robyn Fiso

Do you know or deal with any privately insurance and making a claim for total and permanent disability claims in Qld Australia as my insurance provider is stating that I failed to provide some information and if they had known the information they would have adjusted the insurance or not covered me? They have made a preliminary discussion to refund all of my premiums or I can respond to their questions but they are using information that I did not consent to and have changed the date of when the policy started plus are making sure my response is within their 3 year cut off time when I don’t know how to respond because I answered the questions they asked me to the best of my ability and knowledge at the time of application. Also they are still making insurance deductions from my account?

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