Is my health policy a lemon?

What if you bought a health insurance policy—and then learnt that you could not make any claim for two years? Would you feel cheated?

I did not read the fine print when I bought the health insurance. I freely admit that. 

You know, I know and insurance companies know that no one reads terms & conditions, even millennials with perfect vision. Most people can manage a couple of Facebook posts at a time before tachycardia sets in. This is true whether you’re buying a car, a house or a health insurance policy. But those T&Cs are a minefield. A clever salesman could bury a lot of bad news and cunning escape clauses in the fine print. 

If you have a problem with a policy, it’s your problem. It’s called caveat emptor. You bought it; you’re responsible for ensuring its good quality and suitability before shelling out money.

I bought my health insurance in August 2022 from one of the few companies at that time with plans for Indians over 70. For coverage up to Rs 10 lakh, I pay about Rs 1 lakh annually as premium. In other words, each year I pay about 10 per cent of my sum assured as a premium. Never mind.

When the policy document arrived, I learnt from the Benefits Summary that I was covered up to Rs 80,000 for all hernias, surgeries for benign prostate hypertrophy, and surgical treatment of kidney stones; and up to Rs 3 lakh for cerebrovascular disorders, cancers, other renal problems and broken bones.

I practically felt immortal.

I made my first claim last month, after two healthy, no-claim years. It started with some blood in the urine, but the investigations could not identify the cause or the source. More, and more expensive, tests revealed nothing. My urologist decided to put me under general anaesthesia at Breach Candy Hospital and check out my plumbing with a catheter, a camera and a light, and do a biopsy while he was at it, in case a cancer was creeping up.

All was well; there was no cancer; I was immortal again. But the insurance company rejected my claim of about Rs 2.7 lakh saying that they were among many conditions excluded for two years. 

Huh? 

I called a company representative. The policy document only mentioned my two pre-existing conditions as exclusions, I told him. No one told me anything else was excluded. 

It’s all in the Terms and Conditions, sir, he replied. You’re supposed to have read that. 

He was right: the policy brochure lists 23 categories of conditions, surgeries and treatments that would not be covered by the policy for 24 months—including arthritis, osteoarthritis, gout, spinal disorders, joint replacement surgery, enlarged prostate, cataracts, fissures, piles, ulcers, hernias, all possible cancers, cysts, kidney stones, pancreatitis and others. And surgery of genito-urinary systems, which I underwent and could not claim reimbursement for.

The 23 categories excluded in the policy brochure encompass at least 129 diseases (including 63 cancers), and 66 procedures from policy coverage for two years. 

Let me be blunt: though I bought my policy in 2022, I could effectively claim nothing till 2024. Because it’s all there in the T&C, which no one reads, the insurance company’s corporate posterior is legally covered. The first clause in the policy document that I signed reads: I have read and understood the Terms and Conditions of the policy and confirm to abide by the same.

I have a word for such moments. Huh?

I also have questions. How come the policy’s Benefits Summary did not even hint that there was a boatload of additional excluded diseases in the brochure? I know why: they know no one would buy their policy if they understood they could make no claim for two years. It’s in the insurance company’s interest that no one read the brochure and understand exactly what is included and excluded.

There’s a word for people in my condition. Swived. Look it up.

My narcotic is research. How did the company come up with that exclusions list?

The list of exclusions is issued by the Investment Regulation and Development Authority of India, an independent regulatory body under the Ministry of Finance. An insurer may include all or some of that list but he may not add to it. 

Not that there’s much he could add.

All insurance companies include a similar 24-month exclusions list. The ethical ones ensure you know and understand it before selling you the policy. The unethical ones wait for you to find out the hard way. They understand that one way to confuse ordinary people is to swamp them with fine print and information. It’s not their fault if you don’t read it.

The rationale for so many exclusions is that by withholding payouts for two years, they stay profitable and can offer lower premiums. But I’m paying 10 per cent of my sum assured as a premium—and still footing my own medical bills.

There’s something wrong with an insurance system that considers it equitable to collect premiums but offer nothing in return for two years. Click the QR code below to share your thoughts and experiences on this.

If there are enough others with similar stories, perhaps we can bring the monster to its knees. 

You can reach C Y Gopinath at [email protected]
Send your feedback to [email protected]
The views expressed in this column are the individual’s and don’t represent those of the paper.

"Exciting news! Mid-day is now on WhatsApp Channels Subscribe today by clicking the link and stay updated with the latest news!" Click here!