2 hrs ago
Pregnancy Illness Claims May Face Insurance Disputes
Health insurance does not always pay for medical care during pregnancy.
A policy usually needs maternity benefits or an added maternity rider to cover pregnancy-related expenses.
Sometimes it is difficult to decide whether an illness is caused by pregnancy or is unrelated.
This can lead to disagreements between an insurance company and the person making a claim.
In one example, a pregnant woman had a gastrointestinal infection and severe pregnancy-related vomiting.
Her insurer rejected the hospital bill because her policy excluded pregnancy-related complications.
Insurance companies may ask specialist doctors to help decide whether a claim is covered.
People should check exclusions, waiting periods and maternity coverage before relying on a policy.
After 60 months of continuous coverage, insurers generally cannot challenge a claim for non-disclosure unless fraud is proven.
Standard health insurance policies generally exclude pregnancy expenses unless maternity benefits or a rider is included.
Insurers may dispute hospitalisation claims when an illness overlaps with a pregnancy-related condition.
A woman’s claim for gastrointestinal infection treatment was rejected after she was also diagnosed with hyperemesis gravidarum.
Complications linked to an excluded disease, procedure or treatment may also be denied under policy terms.
The Insurance Regulatory and Development Authority of India says claims cannot generally be contested after 60 months of continuous coverage, except in cases of established fraud.
- Who
- Pregnant policyholders, health insurers and specialist doctors assessing claims.
- What
- Insurers may dispute claims for illnesses or hospitalisation during pregnancy when policy exclusions or links to pregnancy-related complications apply.
- Where
- Under health insurance policies in India.
- When
- During pregnancy and when claims are submitted under policies with relevant exclusions or waiting periods.
- Why
- Pregnancy and certain procedures may be excluded from standard policies, while complications connected to excluded conditions may also be denied.
Policyholders
Insurers
Whether an illness is pregnancy-related
Policyholders
Policyholders may argue that an ailment, such as a gastrointestinal infection, is unrelated to pregnancy and should be covered if the policy otherwise provides that coverage.
Insurers
Insurers may rely on policy exclusions when the patient also has a pregnancy-related condition or when doctors determine that the treatment is connected to pregnancy.
Coverage for complications
Policyholders
Policyholders may expect treatment to be payable when the primary illness or procedure appears covered under their policy.
Insurers
Insurers generally deny complications, side effects or treatments that can be traced to a disease, procedure or treatment specifically excluded by the policy.
Effect of waiting periods
Policyholders
Policyholders may seek reimbursement after buying a policy or maternity rider, but coverage may not yet have become active.
Insurers
Insurers can apply stated waiting periods, including periods of up to three years for maternity benefits and up to two years for some procedures.
Key facts
- Standard policy coverage
- Pregnancy-related medical expenses are generally excluded unless the policy includes maternity benefits or a maternity add-on or rider.
- Example claim
- A woman treated for a gastrointestinal infection was also diagnosed with severe hyperemesis gravidarum; her hospitalisation claim was rejected.
- Claim assessment
- Insurers may use panels of specialist doctors to determine whether treatment falls within policy coverage.
- Maternity waiting period
- Plans with maternity benefits may impose waiting periods of up to three years.
- Other waiting periods
- Cataract and hernia procedures may have waiting periods of up to two years, depending on the policy.
- Permanent exclusions
- Cosmetic and dental treatments are generally permanently excluded under standard health insurance policies.
- 60-month rule
- The Insurance Regulatory and Development Authority of India has directed insurers not to contest claims or policies after 60 months of continuous coverage for non-disclosure, except where fraud is established.
Sources
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