Insurance policy arbitrarily downgraded. Feel Cheated. What is the recourse?

[praveenpinto]

I have a Platinum Health Insurance Policy with United India. The policy has been in force since 2008 and has been renewed every year. This year when renewing the policy they have downgraded me to Gold which means reduced benefits. They are saying that at the time of the issuance of policy I was 38 years and hence they should have issued the gold policy is applicable. However, I did not lie when I got my first insurance. My date of birth and age were specified, i did my medical tests etc. And for the last 8 years the policy has been renewed as a Platinum policy. I have all the policy documents.

As per IRDA regulations 3.1 and 4, I understand I cant be downgraded to a policy with lower benefits and I also cant be arbitrarily downgraded.

I wanted to understand what recourse I have. Which agencies door do I need to knock for justice and will I get justice in my favour.

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[Rahul]

Can you please point me to the "IRDA regulations 3.1 and 4"?

[Rahul]

I have a Platinum Health Insurance Policy with United India. The policy has been in force since 2008 and has been renewed every year. This year when renewing the policy they have downgraded me to Gold which means reduced benefits. They are saying that at the time of the issuance of policy I was 38 years and hence they should have issued the gold policy is applicable. However, I did not lie when I got my first insurance. My date of birth and age were specified, i did my medical tests etc. And for the last 8 years the policy has been renewed as a Platinum policy. I have all the policy documents.

As per Health Insurance Regulation 2016:

13. Renewal of Health Policies issued by General Insurers and Health Insurers (not applicable for travel and personal accident policies)

1. A health insurance policy shall ordinarily be renewable except on grounds of fraud, moral hazard or misrepresentation or non-cooperation by the insured, provided the policy is not withdrawn.
2. An insurer shall not deny the renewal of a health insurance policy on the ground that the insured had made a claim or claims in the preceding policy years, except for benefit based policies where the policy terminates following payment of the benefit covered under the policy like critical illness policy.
3. The insurer shall provide for a mechanism to condone a delay in renewal up to 30 days from the due date of renewal without deeming such condonation as a break in policy. However coverage need not be available for such period.
4. The promotion material and the policy document shall explicitly state the conditions under which a policy terminates, such as on the payment of the benefit in case of critical illness benefits policies.

25. Loadings on Renewals:
i. For Individual products, the loadings on renewal shall be in terms of increase or decrease in premiums offered for the entire portfolio and shall not be based on any individual policy claim experience.
ii. The discounts and loadings offered shall:
1. not be at the discretion of the insurer;
2. be based on an objective criteria;
3. be disclosed upfront in the prospectus and policy document along with the objective criteria, and shall be as approved under the Product Filing Guidelines
iii. No Insurer shall resort to fresh underwriting by calling for medical examination, fresh proposal form etc. at renewal stage where there is no change in Sum Insured offered. Provided that where there is an improvement in the risk profile, the Insurer may endeavour to recognise that for removal of loadings at the point of renewal.

As per above they can increase or decrease the Sum Insured.

[Rahul]

As per IRDA regulations 3.1 and 4, I understand I cant be downgraded to a policy with lower benefits and I also cant be arbitrarily downgraded.

As per policy - Source: UIIC

The entry age for this policy is between the age of 18 years and 35 years. An insured beyond 35 years shall continue to be covered under Platinum policy provided the policies are renewed with us without any break.

I wanted to understand what recourse I have. Which agencies door do I need to knock for justice and will I get justice in my favour.

In case you have a complaint or grievance, you may approach or write or e-mail to the policy issuing office, Regional Office/Head Office for redressal.

Onine: http://www.uiic.in/ugms/html/app1/uiic_grievance.jsp
Offline: https://uiic.co.in/uiiccontactus