Health Insurance Claim of a 49 Years old Insured declined. The Insured had suffered a Heart Attack!

Mr. Ram had returned from the US and started a business of his own in 2018, in Chennai.

He was a little obese but didn't have any health complications. Ram who was interested in acquiring health insurance approached Mr. Manoj who is an Insurance Advisor.

Manoj offered a 5 L health Insurance plan for his family. In 2019, Ram had taken the health insurance.

In 2020, at the time of renewal, Manoj offered a Super top-up Plan for 1 Crore. But Ram being reluctant had avoided the Super top-up plan and renewed his base health insurance plan.

Two months after the 1st renewal of the policy, Ram had suffered a massive heart attack and rushed to a nearby hospital where he was treated and brought back home in 2 weeks. Total medical Expenses had come to around Rs.650000.

With the Help of Insurance Agent Mr.Manoj, He had submitted the insurance claim to the Insurance Company.

Mr. Ram was eagerly waiting for the insurance claim amount and was patiently requesting Manoj for an update.

After about a month time, Mr.Ram received a mail from Insurance Co. stating that his Insurance claim had been declined on the account of non-disclosure of material fact of the Insured.

In Enquiry, Manoj came to know that Mr.Ram was affected by Asthma when he was 15 years old. He took treatment for the same and he had recovered back in a year's time. He was not taking any medication for Asthma for the past 34 years. He had not mentioned this to Manoj as he was not taking any medicine for Asthma while taking the policy, but he had mentioned this to the treating doctor and the same was mentioned in the medical record. The insurance Company on seeing this mention had straight away declined the claim.

Mr Manoj, being a friend of mine had approached me for help.

I had advised Manoj to get a clarification mail from the treating Doctor, that the Asthma he had during his childhood was in no way connected with the present ailment, and to send an explanation mail to the GrievanceRedressal Department of the Insurance Company along with the clarification Mail from the Doctor.

The insured had sent a mail and the Grievance Redressal officer called the Insured Mr.Ram and took stock of the case but there was no proper revert from the Insurer.

Manoj called me and explained his embracing position. I had advised him to request the client to escalate the issue to Insurance Ombudsman marking a copy to the insurance company.

Insured had sent the mail to Insurance Ombudsman and in a week's time, the Grievance Redressal officer had consented to the insured's claim and told him to pay around Rs.1000/- as a loading premium and told that Asthma will be added to the pre-existing disease in the policy and once the same is done the Claim will be reopened for settlement.

The insured had paid the additional premium, and as assured by the Officer, the Claim amount of around Rs.450000/- had been settled by the Insurance company.

Mr Manoj had been appreciated for his effort. In turn, Mayur called me and expressed

his gratitude.

(True Incident. Names have been changed for the sake of privacy.)