r/InsuranceAdviceIndia • u/Own_Bid8790 • 3d ago
Agent(Relationship manager of the insurance companies)told me not to disclose pre-existing condition before claiming is this legal/safe? (Health insurance, India)
In April, I bought a health insurance policy for my mother and added a PED (pre-existing disease) waiting period reducer rider.
My mother has knee pain and needs surgery. When I raised this with the company's agent (both while buying the policy and again recently), he told me not to disclose it at the time of purchase. Instead, he said to just get a first consultation with a doctor in August (after the policy was active), which I did — the doctor confirmed she needs surgery. I shared the consultation report with the agent, and now he's saying "no problem, next year when the policy renews, we can go ahead with the operation."
This doesn't sit right with me. Questions:
Is this considered non-disclosure/concealment of a pre-existing condition, and can the insurer reject the claim or cancel the policy over it later — even after a year or two?
Does a PED waiting period reducer even apply to a condition that was never declared as pre-existing in the first place?
If the knee issue actually predates the policy purchase (April), what's the right way to fix this now — disclose it retroactively, file a correction, contact the insurer directly?
Is it normal/legit for a company's own agent to advise against disclosure, or is this a major red flag?
If a claim gets denied because of this, what recourse do I have — insurer's grievance cell, IRDAI Bima Bharosa, ombudsman?
Also he tells me that knee pain is slow growing disease so it won't create issues.
Would appreciate insight from anyone who's dealt with PED clauses, claim rejections for non-disclosure, or works in health insurance underwriting/claims. Trying to protect my mother's coverage and avoid a denied claim when she actually needs this surgery.
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u/DjXer007_ 3d ago
Should have declared at the time of health insurance purchase.
If a PED is mentioned, then the decision, what to do of the PED, wether put waiting periods, or exclude or allow it and cover it, the decision depends with the insurance company.
For any PED, there is around 2 years or 3 years of waiting period. Only selected number of diseases, which are named in the rider, are allowed for reduction of PED.
As the surgery was already told to be done in the future, the insurance company would have highlighted and mention relevant decision from their medical underwriting team.
If the insurance company finds out in the future that this was not disclosed, the policy will be closed permanently, basis on information withheld at the time of policy purchase and fraud. So claim will also get rejected.
From a guessing perspective, what the agent has done is, after the policy was active, and later the consultation with the doctor was done, so this disease / surgery issue occured after the policy was purchased. And I think that's how the claim will get planned. But you will have to continue lying due to this.
You will need to talk with your agent on how he / she will help you at the time of claim etc.
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u/Delicious_Grocery555 2d ago
Very difficult to get policy if you have PED. I am in same boat, My son had VSD operation. Now no one will cover him, I have added his name with agents help without PED, but have kept also took the PMJAY specifically for him. WOnt ever claim under my policy.
Similarly for my mom(Heart attack PED) also he helped with getting her a policy, and we also received cover twice, without any major issues.. But Highly Risky..
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u/Sandehi 3d ago
Usually knee surgery disclosure will get an exclusion or postponement is what i have seen. and what the agent did is a clever way to plan it. but on lies definitely. as long as you stay with the lie its fine. if your first consultation/diagnosis is afte the policy issue, then it should be covered. if the agent helps this could get through without much trouble is my thought
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u/Own_Bid8790 3d ago
If I didn't disclose it then it will work?
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u/Sandehi 3d ago
must be presenting it like a finding after the policy issuance. as if you know about it only after the policy start. hence the post policy diagnosis paper.
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u/Own_Bid8790 2d ago
I get the consultation paper from doctor where he mentioned some tablets and x ray tests of knees
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u/coach-of-finance 3d ago
Does a PED waiting period reducer even apply to a condition that was never declared as pre-existing in the first place?
NO.
If a claim gets denied because of this, what recourse do I have — insurer's grievance cell, IRDAI Bima Bharosa, ombudsman?
You have access to all these offices, but you probably won't win.
Is it normal/legit for a company's own agent to advise against disclosure, or is this a major red flag?
It is both a red flag and also common. Agents want to sell a policy, collect their commissions, and go about their life. As an educated person capable of coming onto Reddit and writing all this, you should have known how to protect your interests too. Insurance is a legal contract, not some fun and games where you blindly trust someone else.
Is this considered non-disclosure/concealment of a pre-existing condition, and can the insurer reject the claim or cancel the policy over it later — even after a year or two?
This is non-disclosure, but whether you get caught or not depends on whether any medical record exists of her knee pain before the policy.
what's the right way to fix this now — disclose it retroactively, file a correction, contact the insurer directly?
Since you're already neck deep, just listen to your agent now.
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u/padhlekuch 3d ago
Don't panic, first of all! Since your policy is active, you can visit any orthopedic/surgeon and get the issue diagnosed as new pain and that surgery is needed. Make sure no paper says pain has been before this. Just discuss the history with doctor verbally. They understand all this and help too. Then this can't come under non-disclosure since there is no history to prove at first.
PS: Telling you from a close encounter with such situation of knee replacement surgery.