ASK SANJIB: 'My agent wants me to lie to my insurer about my smoking habit'

'Will the premium be high if I particularly want to include 'smoker' in the application?'

Sanjib Jha, CEO, Coverfox Insurance Broking (external link), answers your health insurance related queries.

Please mail your queries to getahead@rediff.co.in with the subject line 'Ask Sanjib' and he will answer all your health insurance queries.

Anoop Vaswani: My Oriental Mediclaim coverage is for Rs 5 lakh under Royal Mediclaim cashless scheme vide PNB. I have completed 36 months, a conditional requirement (a facility only for PNB customer).

In this regard I have a few questions...

Sanjib Jha: Hi Anoop, thanks for sharing your queries, will take them one by one.

1. What's the meaning of 5 lakh coverage? Will I get a full 4.95 lakh for both knees transplant (my hospital package is costing 4.95 lakh from entry to exit)?

Sanjib Jha: A coverage of 5 Lakh means your policy covers you up to 5 lakh and you can claim it. However, the coverage amount for knee transplant depends on insurer to insurer as few of the policies having certain capping on the coverage amount for such treatments.

2. When the hospital sent the proposal to TPA, only 2.47 lakh were provisional sanction. What's the meaning of provisional? I was told that the final amount will be settled once final bill is produced by the hospital. Does it mean that 4.9-2.47=2.43 lakh or so, will be settled and remitted to the hospital by Oriental insurance? 

Sanjib Jha: Provisional Sanction amount is the amount that the insurer approves based on the ailment i.e., knee transplant in your case. The rest of the amount approval is provided based on the final bill generated by the hospital.

3. When I sought clarification from TPA, I was verbally told that now the final amount cannot be decided. Only after the final bill it can be. Nothing said on email. No replies from Oriental insurance of my email query.

Sanjib Jha: For policies issued by Oriental, the claims are handled by TPA (Third Party Administrator). I advise you to raise the concerns to TPA via email or via TPA desk to get the clarification. Also, the insurer can provide the final approval after the final bill is generated by the insurer, deducting the non-approved cost as per policy terms & condition.

4. Hospital insists that I deposit 50% (2.5 lakh) cash from pocket before admission.

Sanjib Jha: As it seems that the insurer has provided pre-approval for 2.47 lakh, the rest amount you will have pay to the hospital & the same will get approved by the insurer once the final bill is generated by the hospital.

5. If I have to pay cash, then where is the cashless scheme?

Sanjib Jha: I advise you to check the terms of your policy. Often certain treatments are not covered in particular policies, which is why it is extremely important to read your policy document thoroughly and ask all your queries to the agent/Insurer before purchase. For specific ailments, there are add-ons offered by insurers and accordingly one should opt for those add-ons.

Harinarayanan Sadasivam Manoharan: I am a mild smoker aged 47 years. I am already having medical insurance for the past 10 years. When I tried to include the concept "smoker" in the renewal application, the agent does not accept and want us to lie with the insurance company. In view of the above the real truth is not disclosed. In this situation, whether any claim particularly related to heart or BP or hospitalization will be affected? Whether full claim will be affected? Please clarify sir.

If I particularly want to include the smoker in the application, whether the premium will be high?

Sanjib Jha: Hi Harinarayanan, to answer your question if it will affect your claim settlement, yes it will and I suggest that you should declare and be transparent with the insurer.

If you have started smoking after the purchase of the policy, then at the time of renewal you should declare it to the insurer. In fact, any material change in activities between renewals should be declared to the insurer; it is then up to them to either adjust your premium accordingly or accept it without a change in the premium amount.

Sunil: I am working in an IT company and have medical insurance coverage to all family members up to 10 LPA.

Apart from company insurance I had taken Bharati Axa Insurance health Insurance for 15 LPA for my family members but 2022 March it got expired and they moved to ICICI Insurance.

At present that insurance is closed. I would like to take a small insurance of 2 to 5 LPA per annum and continue till lifelong with increase in the sum assured without any extra payment on yearly basis and free medical checkup every year and premium to be 5K to 10K per annum.

I am 46 years old.

Sanjib Jha: Hi Sunil, there are policies in the market who will provide you with the said coverage within the said premium grid. You can contact us at 02248971018 to explore the plan details or connect directly with an insurer of your choice to know of the various policies and plan as per your requirement.

You can read more of Sanjib's responses here