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Are you aware that your obesity might prevent you from being granted a health insurance policy? Or that your premiums could be higher if you drink alcohol or smoke? Surprising as it may seem, health insurers can deny coverage or charge higher premiums based on these factors.
Reasons why a health insurance application can be rejected
To buy a health insurance plan, a proposer must disclose various details ranging from personal information like age and gender to health and lifestyle data including past medical history, pre-existing conditions, and smoking or drinking habits.
"The information provided helps insurers decide whether to accept or reject an application based on their underwriting guidelines. A health insurance application might be turned down due to inaccurate information provided by the proposer or if the proposer has serious pre-existing health conditions. In cases of rejection, insurers are to give clear and fair reasons for their decisions," explains Vivek Chaturvedi, CMO and Head of Direct Sales at Digit General Insurance.
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Can overweight individuals obtain health insurance?
Regarding the impact of a person's Body Mass Index (BMI) or weight on obtaining health insurance, Vivek Chaturvedi notes, "The age and health condition of an individual are crucial factors that influence the premium of a policy. Those with a higher BMI can still obtain health insurance, however, they could face higher premiums."
What is the maximum BMI for health insurance applicants?
A healthy BMI is considered to be between 18.5 and 24.9. Below this range, a person is categorised as underweight, while a BMI over 24.9 is considered overweight. Should an individual’s BMI exceed 30, they are classified as obese. Each insurer has different acceptance criteria for high BMI applicants, based on their specific underwriting and risk assessment guidelines.
What should policy buyers keep in mind?
"Ideally, one should aim to purchase a health insurance policy when he/she is young and free of health problems," advises Chaturvedi. "This approach increases the likelihood of your application being accepted and allows you to complete any necessary waiting periods."
"It’s important to remember that once a policy is issued and consistently renewed, its renewal cannot be refused by the insurer, thus guaranteeing lifelong renewability of the coverage," he adds.
Why is health insurance denied based on BMI?
A higher BMI makes individuals prone to conditions such as heart disease, diabetes, and hypertension. These increased health risks may lead insurers to refuse a policy," explains Vivek Chaturvedi from Digit General Insurance. He stresses that insurers must provide clear and transparent reasons for any application rejections.
What other factors could lead to a health insurance denial?
Health insurance claims can be refused for various reasons.
"For example, claims for specific illnesses or pre-existing conditions made during a waiting period are often denied. Misrepresentation of facts during the proposal stage is another common reason for denial," Chaturvedi points out.
In addition, treatments that are experimental or trial-based might also be denied coverage by insurers.
How do tobacco and alcohol use impact eligibility and premiums for health insurance?
Using tobacco or alcohol can significantly affect your health insurance premiums. Insurers might view individuals who smoke or drink as higher risks, which can lead to higher premium costs. In such cases, insurers might also require a health checkup before issuing a policy.
What health conditions significantly alter insurance premiums or eligibility for coverage?
"While insurers cover most health ailments, certain procedures might be excluded from your health insurance policy," says Chaturvedi. It is vital to check the specific details of your policy as coverage can vary significantly between insurers.
According to regulatory guidelines, even individuals with disabilities, mental illnesses, or those who are HIV-positive must be offered health insurance without discrimination.
How does medical history affect insurance underwriting?
During the proposal stage, you'll be asked to share comprehensive details about your health. This includes current medications, past hospitalisations, diagnostic tests, undiagnosed symptoms, and any adverse medical conditions, whether personal or familial.
Additionally, your habits, such as drinking and smoking, are taken into account. This information helps insurers gauge potential risks and pre-existing conditions, which can influence the options and premiums for your coverage.
What can you do if your insurance claim is denied?
If your claim is denied and you disagree with the insurer's reasons, several steps are available for redressal.
You can:
— Contact the insurer for a reassessment.
— If unresolved, approach the Grievance Redressal Officer of the insurance company.
— Then contact IRDAI’s Grievance Redressal Cell or the Insurance Ombudsman.
If these avenues do not resolve the issue, legal remedies such as approaching the Consumer Dispute Redressal Commission are available.
How to avoid being denied coverage?
Honesty is the best policy when it comes to health insurance. So, the applicant must be honest and accurate in disclosing all conditions and health history. Concealing or falsifying health information can lead to claim rejections.
