Anand has taken a Health Insurance Policy from XYZ Insurance Company. The Policy also covers critical illness. He paid premiums continuously without any break and without any claim for 10 years. Unfortunately, he was det

CS Professional · Insurance - Law & Practice · PYQS · December 2022
Anand has taken a Health Insurance Policy from XYZ Insurance Company. The Policy also covers critical illness. He paid premiums continuously without any break and without any claim for 10 years. Unfortunately, he was detected with a disease which is not in the classification of diseases or fall under the definition of critical illness cover of that insurance company. Anand made a claim with the insurance company after his discharge from the hospital, after treatment of the unknown disease. XYZ Insurance Company denied the claim. Anand with much disappointment due to denial of the claim sued the web aggregator who had recommended and issued the insurance policy with critical illness cover to him. Is the Insurer allowed to contest the claim? Justify the answer.

Answer & Explanation:

No, as per the amendment issued by IRDA on 11th June, 2020 (Guidelines on Standardization of General Terms and Clauses in Health Insurance Policy Contracts), health insurers will not be allowed to contest claims once the premium has been paid for a continuous period of eight years (moratorium period). As per the amendment, after completion of eight continuous years under the policy no look back can be applied. This period of eight years is called as moratorium period. The moratorium would be applicable for the sum insured of the first policy and subsequently completion of 8 continuous years would be applicable from date of enhancement of sum insured only on the enhanced limits. After the expiry of Moratorium Period no health insurance claim shall be contestable except for proven fraud and permanent exclusions specified in the policy contract. The policies would however be subject to all limits, sub limits, co-payments, deductibles as per the policy contract.

Topics: Health Insurance

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