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POSTED BY ON February 24, 2012 9:26 pm COMMENTS (17)
Manish ,
I had applied for health insurance policies for my parents ( mother 53 yrs and father 63 yrs ) . I had chosen Apollo Munich health insurance standard plan for two reasons : 1) Life long renewal 2) No loading in case of claims.
To my utter surprise they refused health insurance of 5 lacs cover to my mother cause she is a housewife . When i asked the call center team the reason for this , they said it was order from top bosses. But when i pointed out that the policy wordings do not mention , being a housewife as an exclusion criteria, the call center executive expressed inability to help me in the matter as these were ” orders from above”.
But he offered me four alternatives 1) take only 3 lacs policy for mother 2) take 5 lacs policy for father , only then wil they give 5 lacs policy for my mother. But unfortunately , since my father is a senior citizen , they could give only two lacs to him. 3) take 3 lacs optima restore policy , which gives double coverage if required , but with exorbitant premiums going to lac rupees annually in higher age slabs and 4) to take 3 lacs policy for mother and 3 lacs critical illness rider . But the critical illness rider required the person to be alive after 30 days of critical illness to claim this benefit ( which is absurd as u can die in 5 min in case of heart attack , and then u cant claim this benefit ).
I requested them to allow me to speak to their seniors , but they refused . Finally , not willing to take this unfair trade practices lightly , i threatened them to complain IRDA , launch an campaign on Facebook and Twitter against the company .
Unbelievably , in 5 minutes, they called me back to say that they will issue my mother policy for 5 lacs. I have currently submitted the documents to the company , and waiting for medical tests for my parents . I will update you , if they actually give us the policy .
When i inquired with the executive who collected the documents , he informed me that my case was made an exception. They still dont issue policies above 3 lacs to housewives.
Also , interestingly , they also refused policies to 3 brothers who were photographers . ( Absurd).
My intention of writing this mail was two fold .
1) To make readers aware that , we can fight injustice and we should fight it.(We r the king)
2) To ask Manish , how can we tackle these unfair trade practices , whom can we complain and stop them from making these autocratic decisions .
Manish , we all need your help to fight these injustice against housewives and photographers (and many others for whom the policy has been refused).
Waiting for your guidance !!!
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Hi all…
My friend recently called an executive of Apollo for buying restore… Thank God, she didn’t ho online… It was clear that homemakers can get cover up to 3 lac..if single, no 1_be proposer of policy eg siblings , parents etc.
This is not mentioned anywhere in apollo Munich’s website, policy wording..
The executive said in such case even if online, the policy will not be helpful at times of claims..
When company wants us yo be frank abt our info, & we pay premium in advance…also policy discontinues if premium unpaid… Then why such conditions? & & why not mentioned in policy wording & website clear cut way????
What can be done?
Pl guide
Mostly the agent cheated you and put wrong points in your head so that you dont buy online. There is no issue in buying online. If something is not written in policy document, then its not valid at all
Manish
In order to get the justice, I have to file a complaint against Apollo Munich with the Insurance Ombudsman and fought a long one and a half year battle and finally vide Award No. IO/PUN/A/GI/0054/2014-2015, I could get the justice, the honorable Insurance Ombudsman, Pune award order for full settlement of my medi-calim. I am very thankful to honorable Insurance Ombudsman.
Sandeep Jain
Dear Sandeep, we ‘ll wait for your update. By the way, your case is prime example, why we should fill all the info in policy application on our own.
Thanks
Ashal
I have similar experience and currently undergoing the mental agony from Apollo Munich.
BEAWARE OF APOLLO MUNICH
My previous employer (M/S LKS India Private Limited) have taken Optima Restore Family Floater policy number 6000037432 with inception date 27 Jun 2012 for sum insured of Rs.3 lacs for me and my two family members. I was Executive Director in LKS India Private Limited till 30th November 2013 and I only approved changing from Star Health Insurance to Apollo Munich for self and other employees of the company, hoping for a better service from Apollo Munich, if known that Apollo Munich behaves like this would not have come under the influence of Apollo Munich authorized agent Mr. Vishal Vitthal Otawanekar (80113600) who manipulated us to shift from Star Health Insurance to Apollo Munich assuring the better services (which in fact was also not as per the provisions of 5b of IRDA (Health Inssurance) regulation 2013.
Mr. Vishal Vitthal Otawanekar, himself filled the application form and verified all the desired information to be filled in the form as may be needed by Apollo Munich and the same has been received by Apollo Munich on 20th June 2012 and accordingly put into inception wef. 27 Jun 2012. The same policy was renewed for the current year as well.
It also to be noted that for the self and other employees, I have also taken the personal Accident Insurance Coverage (Policy no. 200007231, dated 26th Jun 2012) for sum insured Rs.10 lacs from Apollo Munich through the same authorized agent Mr. Vishal Vitthal Otawanekar (80113600).
On 18th November 2013, I underwent Angioplasty for the Right Coronary Artery Blockage. I was discharged on 20th November 2013.
I registered the Medical Claim ref. ID 165762 (Apollo Munich) and received letter dated 10th January 2013 from Apollo Munich stating that my claim is rejected and policy is terminated due to non-disclosure of the Ischemic Heart Disease and Cardiomyopathy diagnosed 10 years back.
I refuted the letter and escalated to Grievance Cell of Apollo Munich by giving medically correct technical reasons and references of the definition of Pre-exiting condition waiting period as defined in the terms & wording of the policy and the same was acknowledged by Grievance cell on 14th Jan 2014 mentioning my IRDA token number is 01-14-014896. Mr. Narendra Singh Bhist (Assistant Manager) reverted on 17th Jan 2014 with the same stand of rejection of my health claim and termination of policy Optima Restore Family Floater policy number 6000037432.
I again written to Mr. Narendra Singh Bhist (Assistant Manager) giving him all justifications relevant to the pre-exiting condition and requesting Grievance cell to review under the policy terms but in vain he again reverted on 26th Dec 2013 with same stand.
I wrote the email to IRDA dated 26th January 2014 attaching the 2d-Echo (Annexure-6A) and Angiography report (Annexure-7) of 10 years back (November 2003) which state Non-Obstructive Hypertrophic Cardiomyopathy with normalcy of the Heart Valve & Chambers, normal arteries with no Coronary artery disease, I got email reply dated 27th Jan 2014 from Mr. Narendra Singh Bhist with a changed stand and then saying that the member before policy inception has been diagnosed with;
1. Hypertrophic cardiomyopathy.
2. Rest angina without any blockage of coronary arteries (Angiography –ve, but stress test +ve).
Had these facts been made available to us at inception, the policy would not have been issued in the beginning. Moreover either of the conditions (only Hypertrophic cardiomyopathy without h/o IHD) would have been sufficient to reject the cover… however seems purposely missed to mention here 10 years back.
I again referred the case to Mr. Antony Jacob (CEO of Apollo Munich) and then Mr. Padmesh Nair (Grievance Officer) came in the picture and he reverted on 30.01.2014 saying that he is personally looking at my case and shall revert early next week. In case he need any information from my end, will get in touch with me. But he too didn’t ask of any justification and unilaterally reverted to the previous stand as mentioned in the letter dated 10th January 2014 and even ignoring his own colleague changed stand made on 26th January 2014… This reveal that he has done no any proper and fair investigation of the subject associated with the technicalities of the Cardiomyopathy, its no-relation with Coronary Artery Blockage and the policy terms and wording but prefer to defend the unfair rejection of the claim as was done by his previous colleague.
Now, I am helpless and forced to seek the justice from Insurance Ombudsman under Protection of the Policy Holders interest by highlighting various valid grounds and violation by Apollo Munich as under –
1. The proposal was filled by the Apollo Munich authorized Agent Mr. Vishal Vitthal Otawanekar (it can be verified by the handwriting expert) and he just took my signatures on the 1st and last page saying formality is complete, any material informations (details, requirements or consequences etc.) were purposely never advised by Apollo Munich authorized Agent Mr. Vishal Vitthal Otawanekar, who himself submitted the proposal form to Apollo Munich….
Is’nt it a serious breach of Trust and violation of IRDA regulation (as defined under “Point of sale”) by Apollo Munich Authorised Agent, may be under advice of Apollo Munich to keep the customers dark and least informed so that they can take advantage securing their interests. Insurance Ombudsman is requested to take stern action against such Agents and the companies they are associated with.
2. While issuing the policy, Apollo Munich too purposely never asked for any “material informations” (pre-medical check-up requirements or consequences etc.) as may be required by them for commencing the policy wef. 27th June 2012 but unfairly trying to include in their letter of claim rejection now to take undue advantage.
Is’nt it a serious breach of Trust and violation of IRDA regulation by Apollo Munich.
3. As indicated above, the policy was shifted from Star Health Insurance to Apollo Munich therefore depriving me from the Portability benefits (if any) – Is’nt it i also a violation of IRDA (Health Insurance) Regulations by Apollo Munich.
4. Apollo Munich issued policy terms on page 1 under waiting period stating – Pre-existing disease shall be covered after a waiting period of 36 months.
The Pre-existing condition is defined as per the Def. 26 given on page 6 of the policy – ““Pre-existing Condition: means any condition, ailment or injury or related condition(s) for which insured person had signs or symptoms and/or were diagnosed, an / or received medical advice / treatment within 36 months prior to the commencement of his first being covered under an Optima Restore Policy issued by us.”.
Therefore termination of the policy and rejection of claim is violation of the IRDA circular to all CEO – IRDA / HLT / CIR / 036 / 02 / 2013 dated 20/02.2013 which clearly define the exclusions from the list of critical illness and the Non-Obstructive Hypertrophic Cardiomyopathy is not included there.
The list of exclusion of the policy also doesn’t include the Non-Obstructive Hypertrophic Cardiomyopathy with normal valves/chambers and no thrombus/vegetation/pericardial effusion anywhere as serious illness (example of the judgement on similar case ID n 21-002-0217 given by Ombudsman Bhubaneswar and can be verified at the website:
http://www.policyholder.gov.in/Case_laws_or_Judgements.aspx
Therefore the rejection of claim and termination of the policy on the ground of 10 year old diagnosis of mild Hypertrophic cardiomyopathy (Non-Obstructive type having all normal heart valves and chambers ) and Rest angina without any blockage of coronary arteries (Angiography –ve, but stress test +ve)… is serious breach of IRDA guidelines.
5. There is no definition of material fact in the policy to state that the pre-existing condition comes under the definition of Material fact.
The policy terms and wording nowhere state that the non-disclosure pre-existing condition if diagnosed prior to waiting period of 36 months will lead to the termination of policy and rejection of claim.
This is again a deliberate violation of from the policy wordings as per the IRDA guidelines vide aforesaid circular. Please compare Page 1 of the policy issued by Apollo Munich with the standard conditions of the IRDA vide aforesaid circular.
Is this not proves that Apollo Munich is misleading the Policy holders by not complying with the wordings of the policy as enforced by IRDA.
6. The policy fall under the IRDA definition of – Groups :- therefore depriving me from the benefits as may have been prescribed by the IRDA under the subject policy which is taken by my employer under individual name also – Is’nt it amount to the violation of the IRDA guidelines.
7. The diagnosis of Non-Obstructive HCM was 10 years old and 2d-Echo and CAG reports clearly reveal the normalcy of heart valves/chambers and no existence of Coronary Artery Disease, even the latest 2d Echo dated also states the same with no significant change from the 10 year old report (Attached as annexure 6B).
I have lived quite a disciplined and claim less life and have no other complications like Hypertension, BP or Diabetes which may have nexus with Coronary Artery Disease and I have lived Healthy/normal claimless life before and after above mild HCM detection.
Further, HCM is a permanent condition of the heart caused with unknown reasons and generally don’t affect person and has no-relevance with the present ailment and doesn’t cause/result Coronary Artery Disease … which even can be checked/verified from qualified Cardiologist and medical literature/books but Apollo Munich never felt necessary to look into this technical aspect.
As other reputed institute, The National Heart Lung and Blood Institute (NHLBI) define Hypertrophic cardiomyopathy (HCM) as under –
Some people who have HCM have no signs or symptoms. The disease doesn’t affect their lives” – http://www.nhlbi.nih.gov/health/health-topics/topics/cm/
The Wikipedia state : Asymptomatic patients : A significant number of patients with hypertrophic cardiomyopathy do not have any symptoms and will have normal life expectancies”.
http://en.wikipedia.org/wiki/Hypertrophic_cardiomyopathy
Medeicine net states: Many people with HCM have no symptoms or only minor symptoms, and live a normal life.
http://www.medicinenet.com/cardiomyopathy_hypertrophic/article.htm
Clevelandclinic also state: Many people with HCM live a normal life and do not experience health-related problems.
http://my.clevelandclinic.org/heart/disorders/hcm/default.aspx
I too had/have no signs or symptoms after diagnosis of Non-Obstructive Hypertrophic Cardiomyopathy 10 years ago and never ever felt shortness of breath, arrhythmias, or inability to exercise … If Insurance Ombudsman or honourable court ask I am ready for any Fatigue Test or running with Mr. Antony Jacob (CEO of Apollo Munich) to ascertain who’s heart is more normal and stronger.
My cardiologists, Dr. Shivram Bonagiri and Patki Dr. Nitin Patki are also ready to furnish the technical facts with the relevant authorities (if asked) and the same was never felt necessary by Apollo Munich while unilaterally rejecting my claim.
8. Coronary Artery Disease was 1st detected on 15th Nov. 2013 during Angio Scan and CAG on 18th Nov. 2013 and angioplasty was done same day. Thus It is clear that Coronary Artery Blockage was not a pre-existing disease.
Under the above facts, I wish to state that
1. I am honest in my disclosures and Insurance Ombudsman can understand that if I would have knowingly hidden the disclosure of my 10 years back HCM detection, I could have not submitted the discharge card with past history and manipulated it but it was never the case and I have never tried manipulating any document, which proves my honest intentions in the good trust with Apollo Munich.
2. the stand by Apollo Munich that policy would have not been issued by the Apollo Munich is unfair and amounts to the violation of IRDA guidelines, when claim was raised after paying handsome premiums, since the symptoms and diagnosis of Non-Obstructive Cardiomyopathy 10 years back doesn’t not fall in the category of the Critical illness and even if it would have been mentioned at the time of proposal stage they would could have not reject the cover as per IRDA guidelines since it being under Group and cover is being taken by employer for its employees and if rejected the entire group cover would have been withdrawn by the company at the proposal stage itself and this was known to the Apollo Munich authorised agent and Apollo Munich.
3. my claim is absolutely genuine and payable by Apollo Munich on technically justified grounds and Protection of Policy Holder Interest act.
However, Apollo Munich is intentionally rejecting the claim on the basis of unfair grounds in accordance to their now apparent unethical and bad business practices and causing me severe mental agony. I have raised the request up to the topmost management level of Apollo Munich but in vain.
I have requested Insurance Ombudsman to kindly intervene and do the justice with me under the provisions of “Protection of Policy Holder Interest” by advising Apollo Munich to settle my claim without any delay…. Let’ see what happen…but I will not leave my battle till the Apex Court of India.
Sandeep Jain
In order to get the justice, I have to file a complaint against Apollo Munich with the Insurance Ombudsman and fought a long one and a half year battle and finally vide Award No. IO/PUN/A/GI/0054/2014-2015, I could get the justice, the honorable Insurance Ombudsman, Pune award order for full settlement of my medi-calim. I am very thankful to honorable Insurance Ombudsman.
Sandeep Jain
Dear Sathisp, please feel free to discuss.
Thanks
Ashal
I am going through a issue with Apollo Munich guys. I am not sure if this article is still valid? Can I publish my experience, I am not sure if this article is still tracked?
Dear Anand, cross selling means selling one product from the sister company or a tie up company while the basic customer is not the original customer for the same services or products but is the customer of other services or products.
Here in this case, Primary purchase is health insurance cross selling is done from Apollo Pharmacy for purchase of medicines from it.
Thanks
Ashal
Dear Ashal,
What is a cross selling?
Dear Mahavir ,
I am ok with your comments and accept them to a certain extent.
I am a doctor by profession . I am a kidney specialist in a reputed South Mumbai hospital .Being from a medical background , i can easily understand why companies would want to deny policy to diabetics. I have no objection if a policy is rejected on medical grounds or accepted with additional loading .
But , with what logic or common sense can you justify denying policy to a housewife ? Also , its easy to realize that , it does not seem to be a policy matter with Apollo Munich , cause they were offering policy to my mother ( housewife ) , if i was taking another policy of 5 lacs for my father . In my case , since my father is a senior citizen, they were not able to offer him 5 lacs coverage and hence they refused the policy for my mother .
Also how can you justify refusing policy to photographers . Photography is not a high risk profession like army or pilot.
Lastly , I did not force them to issue policy to my mother , rather i asked them to add ” housewife” as an exclusion criteria in their policy wordings . Had they done that , i would have accepted it , as it was their policy decision.
Manish and Mahavir , if you agree to my comments , then i need your guidance on how and whom to complain,against Apollo Munich , in case they continue these tactics .
PS: thanks for letting me know that all critical illness riders require you to be alive for 30 days to claim it . Its a bit absurd though.
Dear Rmohan, the discount offered in Apollo pharmacy is nothing but a cross selling. Although it’s beneficial to you as a consumer.
Thanks
Ashal
Hi Amit,
Bravo…well done! We as customers are king!
I have too taken Apollo Munich floating cover for 5 lacs for myself, wife and kid. Hope I don’t need to use it, but if I need to use it, hope they do cashless cover
Btw, One advantage I get out of this is there is a 6% discount in all apollo pharmacies…very pleasant surprise to me
I have an issue with your comment . You said “I hope they do cashless cover” . Are you saying you are not clear whether they have cashless claims or not ? DIdnt you even check that before buying the policy ? Is it not mis-buying !
Hi Manish,
What I actually meant is that when they do cashless cover, I hope they do it properly and don’t come up with exclusions for each and everything. Since it was a Sunday I didn’t express my comment properly
Thanks,
Ram
I am not aware of the company rules . It might be an internal policy also , but looks like they are taking people on the ride too ..
Let me enquire about it from medimange and ask them to put their comments, as they are domain experts .
Manish
Dear Amit, by making more & more voice for our rights & at the same time being vigilant as well as knowledgeable for our rights, we may stop such kind of malpractices.
Thanks
Ashal