The Delhi High Court directed United India Insurance (UII) to pay Rs 5 lakh to Jai Prakash Tayal who has a genetic disorder that causes blood to pump less effectively. After his third hospitalisation, the insurance company rejected his claim citing a “genetic exclusion clause” in his renewed contract. The High Court, observing that even diabetes and cardiac diseases meet the broad definition of genetic ailments, pulled up UII and the Insurance Regulatory And Development Authority of India (IRDA). The HC declared, “The broad exclusion of genetic disorders from insurance contracts/claims is illegal and unconstitutional”. (The Indian Express, February 27, 2018.)
A pragmatic yardstick for successful life innings in India, is if you’re able to avoid a law court and a hospital. Tayal had to suffer both but his case will set an example for victims of indecipherable insurance policies where fine print offsets the best laid financial plans. A hospitalisation of a family member comes with a series of small and large shocks, the first of which is the sickening realisation that the synonym for Intensive Care Unit should be, Somehow We’ll Keep You Alive. As I discovered recently, medicine is a lot like detective work. Diagnosis happens by the process of elimination. In serious situations that need to be contained immediately, the first solution in a hospital is a bucketful of antibiotics, anti fungals and suppressants, followed by monitoring the patient to see what’s working. It’s experience-based guesswork. While the team of doctors is tinkering around with the best possible permutation-combination of drugs to start treatment, the family, entirely at their mercy, inhabit no man’s land. The bills keep mounting. If the patient is lucky enough to make it out of the ICU, the nightmare is far from over. After negotiating the alternate universe that is a hospital— emerging bruised and battered but still standing—another intense shocker awaits. Getting your insurance claim.
It was probably easier for Moses to extract water from a stone than it is for regular people to collect their dues from health insurance companies. It’s a universal horror story. After dutifully paying their premium for 24 years, my parents discovered their policy barely covered 30 per cent of their bill the first time they availed of a hospital stay. Millions of people are left shattered at their most vulnerable moment, once they discover that the modus operandi of most insurers is to make it as difficult as possible to collect your claims. It’s not necessarily that insurance companies are trying to fleece you. But they’re not going out of their way to tell you about their exclusionary categories either, which is a long and arbitrary list. It’s up to you to read the disclaimers tucked away deep in the fine print. They usually win, because the critically ill lack the wherewithal to take on these battles.
Chances are, if anyone bothered to read those dreaded terms and conditions, one would be prepared that even the best available insurance will not fully cover an illness or injury. It comes as a blow because most of us focus on the wrong aspects of life. We spend more time researching which TV to buy than think through a plan for how much we may need to shell out in case of a life-threatening disease. Frustratingly, we are bombarded by full-page life insurance ads and TV spots, promising low rates and guaranteeing full coverage. They usually feature old people serenely reading newspapers like they don’t have a care in the world as if their lives are going to stretch out till eternity. If a policy sounds too good to be true, it probably is and must be viewed with caution. Interestingly, among those thousands of tiny clauses, is the information that the same treatment by the same doctor within the same hospital can cost up to 50 per cent more based on the category of room you choose — general, private or shared. This is stuff no agent shares. So an illness and the cost comes like a sledgehammer. The best insurance, rather, the only reliable insurance, is staying healthy.