Friday, Oct 6 2023
Source/Contribution by : NJ Publications

Health insurance has always acted as a crucial safety net, giving people and families access to financial security against unanticipated medical expenses. Despite its importance, there are still many complaints that arise in the world of health insurance. Policyholders frequently experience difficulties and annoyances due to a variety of reasons, such as coverage restrictions, claim rejections, postponed settlements, and insufficient customer service. 

When there is a perceived mismatch between policyholders' expectations and the services offered by insurance firms, grievances related to health insurance arise. These grievances can undermine the intended purpose of health insurance, creating stress and financial burdens on individuals when they are in need of the most support. In this article, we will bring light to some of the common challenges or grievances that buyers of health insurance policies may experience if they are not careful and have not been fully honest.

1. Mis-selling: When an insurance advisor gives the policyholder inaccurate or misleading details about a policy's features, benefits, or terms, this is known as mis-selling. This may result in the policyholder buying a policy that does not meet their needs or may not offer the coverage they had been expecting for. Thus, individuals should be cautious when buying insurance coverage to safeguard themselves from mis-selling. It's crucial to thoroughly understand the policy terms, read the fine print, ask questions, and compare policies from different insurers before making a decision. In order to make sure they select the insurance products that best suit their needs and financial objectives, one can make sure that you are dealing with established and reputed brokers in the market. 

2. Wrong Policy Documents/ Copy: This complaint happens when an insurance policyholder pays the premium but does not receive the policy copy as intended. Alternatively, they may receive a policy document that contains inaccurate information about the policyholder, the scope of coverage, or the type of policy. In these situations, receiving the appropriate policy paperwork is essential for ensuring the validity and accuracy of the policyholder's coverage.

The policyholder should speak with the insurance advisor or the insurer right away to get this anomaly resolved. To assist the organization in locating the payment and determining the problem, they should offer documentation of premium payments as well as all pertinent information. Policyholders should constantly double-check their personal, contact and other crucial information before giving it to the insurance firm to avoid such problems. They should also keep track of any premium payments, correspondence with the insurance provider, and other pertinent information associated with the acquisition of the policy for future reference.

3. Claim Approval Delays: Claim approval delays happen when an insurance provider takes an unusual long time to examine and approve a submitted claim. When a policyholder relies on the claim amount to pay for immediate needs like repairs, medical bills, or other urgent needs, such delays might put them in a difficult financial situation and cause them inconvenience.

The following actions can be taken by policyholders to reduce claim approval delays:

  • Submit the claim with correct and comprehensive documentation.
  • Engage completely in any investigation that your insurance provider requests.
  • Maintain ongoing communication with the claims department and check in on the status of the claim.
  • Be familiar with the terms and conditions of the policy to avoid any unpleasant surprises when filing claims.
  • In case the insurance provider asks for more details or supporting documents, provide it as soon as possible.

However, several times, the guidelines of the insurer may call for extra caution in situations where the claim amount is very high. In such cases, after the claim is handled at one end, a certain length of time passes before your claim is sent and you receive the insurer's consent. The transmission of information pertaining to your claim to you may be delayed as a result of this gap in time.

4. Claim Rejection: When an insurance company rejects a claim for various kinds of reasons, it is known as a claim rejection. It can be as a result of relevant information not being disclosed during the insurance application, the claim not satisfying policy requirements, or the claim falling under policy exclusions. Rejecting a claim can be upsetting, particularly if the policyholder sincerely feels that their claim should be accepted.

Policyholders should thoroughly study their insurance plans, comprehend the coverage, and make sure all requirements are met in order to avoid having claims denied. During the application procedure for a policy, it's imperative to provide all pertinent information honestly. If your claim gets rejected, the insurance provider is required to disclose the reason. Additionally, you can discover the grounds for the denial of your claim. However, the IRDAI, Insurance Regulatory and Development Authority of India, mandates that insurance providers provide justification for denial of claims.

Grievance redressal: 

In India, the IRDAI is the regulator overseeing the insurance industry and defending the rights of policyholders. In case of any grievance or anomaly, the policyholder should first make sure that he/she has read all the policy related documents and fine print carefully and that the complaint or claim is genuine and can be backed with relevant supporting facts, communications and documents. Once convinced, the policyholder can initially get in touch with the insurance advisor for further clarification and guidance. One can also contact the concerned insurer customer service or grievance department for the resolution. Ideally all common and addressable complaints would be resolved by now. However, in rare cases of a genuine complaint yet not resolved, the last option left is for the policyholder to escalate the situation to IRDAI for additional support and resolution. 

Bottom line: 

The chances of any grievance happening can be greatly reduced if one is following proper due-diligence procedures, has researched and read all the policy related documents (especially policy terms), inclusions and exclusions, and has provided all the necessary and correct details. Also, working with established and reputed insurance brokers in the market helps a lot in all these aspects. The right advisor will also help you in identifying the suitable products as per your requirement and needs. Ultimately though, your active participation and understanding is crucial in your entire experience of having insurance policies.

Imp.Note: We are registered NJ Wealth Partners and this interview published is sourced from NJ Wealth with due permissions. Reproduction of this interview/article/content in any form or medium by any means without prior written permissions of NJ India Invest Pvt. Ltd. is strictly prohibited.

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