Q: I could not reach the panelists over phone during discussion on medical insurance telecast on NDTV and would like to ask this question. It is very clear that diabetes and hypertension are not diseases in the real sense of the word but they are conditions from which people suffer. How can the Insurance company (govt.) deny payments for angioplasty when a person is hypertensive? What is the rationale behind this? Blocks can appear all of a sudden in a person even if he is hypertensive or not. The argument is that there will be no payment for preexisting diseases. But in the private sector they advertise that the preexisting diseases are covered after the fourth year if it is renewed for 4 years. Why do regulating authorities allow double standards by different players? I am a 59 year old person and have taken insurance after my retirement for emergencies like heart attack in old age. I developed hypertension due to mental pressure during service, am taking drugs and a doctor has certified that it is under control(130/80). I am told that I will not be paid for hypertension and related conditions. Why should I be penalized if there is a heart attack which could be due to other reasons like increase in cholesterol or triglyceride level? Please clarify these points as it is not clear why hypertensive persons are denied payment for heart ailments?

A:At the onset, let me thank you for asking this question, which was briefly touched upon during the programme. Your concern is well founded and it is one of the foremost concerns in this area. The contentious issue of Pre Existing Disease has plagued the health insurance sector in our country ever since the inception of this policy. For no other general insurance product (for that matter even including life insurance) have so many complaints been filed as for health insurance where in the pre existing disease constitutes the majority of the complaints. The insurance model is based on the assumption that a certain event in the future has to happen which may have adverse consequences for a person. To offset the loss arising out of this adversity, the person may buy an insurance cover. Now, the premium for this cover is directly linked to the nature of risk involved and in general terms , higher the risk , higher the premium. Coming to our issue, when the health insurance policy was framed, it was decided that the risk of claims for a pre existing ailment are very high. More over, to offset this high risk the only option was to increase the premium amount. Consequently it was discovered that at such high value of premium amount, the marketability of the policy was not feasible and thus it was decided not to include pre existing diseases. More over, had this been included, it would have further led to people with grave and serious existing ailments, to purchase the cover leading to an ever increasing adverse selection. Insurance must be seen as a form of pre-payment for utilising medical services. Ideally, people should purchase it when they are young and healthy and the possibility of their falling sick is low. Premium collected from them will go towards subsidising the medical costs of those people who are sick (and generally older). Unfortunately in our country, awareness regarding health insurance is low resulting in a smaller pool of insured people. Alongwith, the profile of people who take health insurance is skewed towards those who are either sick, older generation, or those who have a genetic or otherwise predisposition to falling sick. This makes the insurance pool (premium amount collected) to pay for medical services , grossly inadequate. And as a result, the health insurance portfolio for all the insurance companies in the public sector, is loss making. Add to this the losses arising out of fraud and provider malpractices. All of the above has led to insurers looking for capping the losses. Being particular about pre existing diseases and conditions is a result thereof. The intention of the insurance contract clearly states that any illness arising out of a pre existing illness or condition will not be payable by the insurance company. And it is this clause that causes the majority of discontent in this field. This should explain the rationale of not covering the pre existing diseases. When you say that it is very clear that blood pressure and diabetes are not diseases but are conditions- it becomes very simplistic, while it is not. It is an interpretation that is being put forward while the insurance companies do not agree with it. In the past there may have been a considerable number of cases where insurance claims have been obtained despite the presence of abnormal BP and sugar levels in the body which further goes on to show that no uniform policy has been enforced. I should think that, as unclear the situation on this issue is, it has been lucidly explained above. In future pre existing conditions may get covered from day 1 but the benefits that a policy holder gets will greatly be reduced. Insurance companies covering pre existing diseases after 4 claim free years effectively rule out major diseases if you read their fine print. It is the right of every insurance company to list its terms and conditions and I dont think it can be an issue for the regulator to disallow such product variations. Any claim by you arising out of reasons other than your existing conditions of BP will be fully paid for by the insurer. In case the insurance company feels that the illness is due to a pre existing condition, then the onus of proving the same lies with the insurance company. I hope that effectively answers the questions raised by you. In case you need any further information or clarification, please do not hesitate to let me know.