Insurance Buyer Rights

 

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What are your options for insurance related grievances ?

 

Insurance customers mostly accept the unilateral decisions taken by the insurers, as most of them believe that fighting an insurance company is a lost cause. However, things are changing slowly. The health insurance space has seen a spate of court cases lately, with several judgements going in favour of the insured individuals. Recently, the Insurance Regulatory and Development Authority (Irda) pulled up the state-owned New India Assurance for violating the provisions after the regulator received complaints on overcharging of premium and delay in claim settlements. These instances simply prove that it pays to be aware of yours rights as a consumer.

Justifying The Premium

Sure, the insurance company fixes the premiums, but that doesn't mean it can do that arbitrarily. The company has to adhere to the premium structure mentioned in the product details filed with Irda. But how would you know whether you are being overcharged or not? Premium is charged by the insurance company according to an Irda approved premium chart. This can be easily obtained from the insurer's website or its office. Typically, premiums go up on renewal with the policyholder's advancing age, claims made in the previous year and revision in the insurance company's premium chart. Now, if the insurer has stated that the rise is due to your age, you can easily verify it with the help of the premium chart. If it is because of claims made in the previous year, again, the claims loading structure mentioned in the policy wordings will come to your aid. Then, there is the modification in the premium chart. The insurance company can apply for changes in premium (and the loading policy), in view of healthcare inflation, or a justifiably large claim ratio. Such premium changes need to be justified and approved by Irda. Before calculating or validating premium, you should check whether there is a new premium chart.

Renewal Is Your Right

In most cases, that is. If the company has specified that the renewal will cease at a particular age of, say 65 or 70, there is little scope for recourse. If policy wordings are silent on this issue, though, renewal cannot be denied. Moreover, Irda has instructed companies not to deny renewals simply on account of claims being made in the previous year. A renewal request can be turned down only in case of frauds or misrepresentation of facts by the insured. This is also applicable to the cancellation of a policy before its tenure expires.

Processing Within Deadline

Since cashless claims are settled almost instantaneously, delays in processing are mainly associated with reimbursement claims. Usually, health insurers insist that you must submit the claim document, along with the bills, within 14-30 days, depending on their policies. Some could also insist on being intimated about the hospitalisation within seven days, though the documents could be submitted later. If your claim sanction is delayed even after following all these steps and complying with all document related formalities, you can take your insurer to task. Policyholders have the right to claim interest if the pay-out is delayed beyond 30 days after the acceptance of the claim.

Other Rights

There are various other issues about which the insured should be vigilant, such as: the timeframe for processing and settlement of claims; the financial limits of a surveyor (there are cases when a surveyor is appointed for claims which are higher than his eligibility limit); that piecemeal information cannot be sought; that a second surveyor cannot be appointed by the insurance company; various circulars regarding standardised definitions, premium, etc. If you are buying a health policy with a term of two years or more, you are entitled to a 15-day 'free-look' period, during which the policy can be cancelled (and the premium refunded) if it doesn't satisfy your expectations. In addition, the insurer cannot delay the decision on approving or rejecting your application for a cover beyond 15 days of submission. Court verdicts constitute another area you need to keep an eye on.

Redress Your Grievances

If the insurer fails to serve you to your satisfaction despite meticulous compliance, you can flag off the issue to the company. You are entitled to receive a written acknowledgement from the insurer within three working days of the receipt of a complaint. If it is not addressed during this period, the company is supposed to resolve the grievance within two weeks of its receipt and send a final letter of resolution. Your next stop should be Irda – through the online platform (www.igms.irda.gov.in) or the Insurance Ombudsman offices. The final recourse is to approach the consumer forum or a court of law. If a representation is made to the Irda, the insured should be vigilant and not wait endlessly for action or communication from Irda, as the time lost there can result in the complaint getting time-barred.

Finally, if you are not satisfied with your insurer's services, you can always propose to "port", or switch your policy to another health insurer while retaining all the continuity benefits.

 

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