Health insurance repudiation in India refers to the rejection of a claim made by a policyholder by the insurance company. This usually occurs when the insurer believes the claim is not valid under the terms and conditions of the policy. In India, repudiation of health insurance claims is a significant issue that affects consumer trust and access to timely healthcare.
Common Reasons for Repudiation:
- Non-disclosure or Misrepresentation – Failure to disclose pre-existing conditions or other relevant health information at the time of policy issuance.
- Policy Exclusions – Claims arising from illnesses or treatments excluded under the policy (e.g., cosmetic surgery, certain pre-existing conditions during the waiting period).
- Lapsed Policies – Claims made under policies that have not been renewed or have expired.
- Fraudulent Claims – Suspicion of forged documents or fraudulent hospitalization.
- Treatment Not Covered – Procedures or treatments outside the scope of the policy coverage.
Legal Framework and Redressal:
Policyholders in India are protected under:
- Insurance Regulatory and Development Authority of India (IRDAI) regulations, which mandate fair claim settlement practices.
- Consumer Protection Act, allowing aggrieved customers to file complaints in consumer courts.
- Ombudsman Scheme, offering a cost-free and quick grievance redressal mechanism.
Recent Developments:
- The IRDAI has tightened norms around repudiation, pushing for greater transparency and fair practices.
- The Supreme Court and various consumer forums have ruled in favor of policyholders in cases of unjustified claim rejections, emphasizing insurers’ duty of good faith.
Preventive Measures:
To avoid repudiation, policyholders should:
- Disclose all medical history honestly.
- Read policy documents carefully, including exclusions and waiting periods.
- Keep records of all medical treatments and communication with insurers.
