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might be aware that it covers certain diseases only after a waiting period of four claim-free years. But do you know that conditions related to genetic disorders are not covered at all? And that claims relating to certain self-inflicted ailments-like cirrhosis of the liver due to excessive intake of alcohol, lung and throat cancer due to tobacco use, and HIV-can also be rejected by the insurance company. All this is explicitly stated in the policy terms and conditions but buyers seldom go through the fine print. Even the agent will not disclose these intricate features of the policy for fear of losing business. "An agent will not usually tell the buyer about all the exclusions in the policy," says Rahul Aggarwal, chief executive officer of Optima Health Insurance.

Congenital diseases

Conditions such as cataract, hernia and sinusitis, which take a few years to develop into a full-blown ailment, are usually covered after a waiting period of 1-2 years. But genetic disorders, such as cystic fibrosis, Down's Syndrome, thalassemia and congenital anemia, don't ever get covered. "Often a congenital disease is confused with pre-existing diseases, which are covered in most cases after the fourth policy year," says Harsh Roongta, chief executive officer of Apnapaisa.com. "If a person is hospitalized due to an illness and it is discovered that it is a congenital disease, the insurance company may deny the claim," he adds.

There are instances where a person may never know that he suffers from a genetic defect. "If one has regularly undergone medical check-ups but a pre-existing ailment never showed up in the tests, the courts have held that the cost of treatment of such an ailment has to be paid by the insurance company," says K.S. Sankar of Medimanage Insurance Broking. Insurers too are lenient if they know that it was a genuine oversight. Says Subrahmanyam B, vice-president and head (health vertical) at Bharti AXA General Insurance: "If the patient genuinely mistook an earlier heart attack to be only a chest pain due to indigestion, we will consider the claim."

Self-inflicted ailments

Another reason why a claim can get rejected is if the ailment has been self-inflicted. At the time of application, one has to declare whether he consumes alcohol or uses tobacco. If a person has stated that he is a teetotaler but end up in hospital with cirrhosis of the liver, the claim may be denied. However, there is a fuzzy line of subjectivity here. "Insurance companies deny claims for treatment of cirrhosis in such cases under the exclusion self injury. But they pay for treatment of cancer even of smokers. The logic is that while, in nearly 100% cases, the cause of cirrhosis of liver is alcoholism, no such empirical relationship exists between cancer and smoking," says Sankar.

Investigative diagnostics

Similarly, investigative diagnostics are not covered by insurance if there is no proof of treatment. "There have been cases where doctors are unable to detect a problem and suggest a battery of tests. Later the tests reports revealed that nothing is wrong. The claims were rejected because the hospitalisation was primarily for diagnostic purposes," says Roongta. Even if the hospitalisation and the tests were prescribed by a qualified doctor, the claim will still be rejected. "The tests may have been conducted because a doctor prescribed them but there is nothing to justify payment. The insurer will pay only for curative treatment," justifies Sankar.

Besides, policies reimburse costs incurred after hospitalisation for up to 90 days. This too has the condition that the 90-day period must commence and end within the policy period.

Source: ET Bureau