Insurance ombudsman flags ‘deviations’ in health policy

The insurance ombudsman for Tamil Nadu and Puducherry is planning to take it to the notice of the Insurance Regulatory and Development Authority of India (IRDA), the issue of insurance firms deviating from norms relating to the coverage of pre-existing diseases.

“We have received some complaints relating to disputes regarding coverage of pre-existing diseases in health insurance policies. The main issue seems to be non-compliance with the regulatory framework,” M. Vasantha Krishna, insurance ombudsman, who took charge in May, told
The Hindu

As per guidelines issued by the IRDA, only diseases diagnosed or treated in a period of four years prior to the policy inception are to be considered as pre-existing diseases. Such pre-existing diseases are not covered during the first four years of policy but covered beyond four years. “We have seen policy wording permanently excluding pre-existing diseases, ignoring the four-year limit,” he said.

According to experts, customers have faced hardship due to the issue which has led to lot of disputes.

“Coverage of pre-existing diseases has been a grey area. I have known cases were coverage of eye treatment was excluded permanently because the person was wearing glasses. This is a mockery of the IRDA guidelines; I am sure the IRDA is not going to take this issue kindly and would come down heavily on insurance companies,” Harsh Roongta, a registered investment adviser, said. “There is a misconception that pre-existing illnesses can never be covered by one’s health insurance policy. This misconception should go away and regulator’s help in this regard would help,” M. Somasundaram, liaison officer, Consumers Association of India, said. Health insurance-related complaints account for more than 90% of the non-life insurance cases handled by the insurance ombudsman for Tamil Nadu and Puducherry.

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