Pre-Existing Disease Waiting Period in Health Insurance

Posted on: Jun 21, 2024 | 3 mins | Written by: HDFC ERGO Team

Pre-Existing Disease Waiting Period in Health Insurance

Health insurance is one of the most essential financial safeguards you can have, which is why choosing the right plan is so important. While evaluating a policy, it is crucial to understand key terms such as pre-existing diseases and waiting periods. Knowing what these mean will help you make informed decisions and avoid surprises when you file a claim.

What are Pre-Existing Illnesses?

A pre-existing disease in a health insurance or mediclaim policy is a medical condition that the policyholder already has before the health coverage begins. This includes diseases such as diabetes and hypertension.

Waiting Period for PED

If you have a pre-existing disease, you will have to wait for a stipulated period before you can make a claim on the policy. The PED waiting period differs from insurer to insurer and is also based on the specific type of disease. The periods usually range between one and three years.

Types of Waiting Periods Under Health Insurance Plans

When you buy a health insurance plan that covers pre-existing diseases, it is important to understand how waiting periods work. Some PEDs may have a waiting period as short as 30 days, while others may require 2 to 3 years of continuous coverage. As per the latest IRDAI guidelines, the maximum waiting period for any PED cannot exceed 3 years.

Listed below are the common types of waiting periods you may find in your policy document:

• Waiting period for PEDs:

This applies to all pre-existing conditions, such as diabetes, hypertension, chronic arthritis, and allergies. The duration typically ranges from 1 to 3 years. You can file claims for these conditions only after the respective waiting periods are completed.

• Waiting period for specific conditions:

Certain ailments, such as hernia, joint replacement, cataract surgery, and bone-degenerative disorders, come with their own waiting periods. The duration varies by insurer, so review your policy to know when you can submit claims.

• Initial waiting period:

All health insurance plans include a standard 30-day initial waiting period for most illnesses, except accidental injuries. Claims filed during this period may be rejected.

• Waiting period for critical illness:

This applies to serious conditions such as cancer, stroke, and major cardiac issues. Most insurers impose a waiting period of up to 90 days before you can file claims for critical illness treatments.

• Waiting period for maternity insurance:

Maternity benefits and newborn coverage often have a waiting period of 3 to 60 months, depending on the policy terms.

Regardless of the type of waiting period that applies, always read your policy document carefully. Knowing the exact duration helps prevent claim delays or rejections.

Why is It Necessary to Disclose PEDs While Buying a Health Insurance Policy

Now that you understand what is PED waiting period in health insurance, it is equally important to know why full disclosure of your medical history is essential when buying a policy. Some people avoid declaring PEDs because they believe it will increase their premiums. However, non-disclosure can lead to more serious consequences.

If an insurer discovers later that you hid a pre-existing condition, your claim may be rejected, especially if it relates to treatment for that condition. In some cases, insurers may even cancel the policy altogether as a penalty for withholding information.

Full disclosure of PEDs is important for the following reasons:

• To avoid claim rejections.

• To help insurers accurately assess your risk profile and offer the right premium and coverage.

• To allow insurers to set an appropriate waiting period based on your specific condition.

• To prevent disputes or legal issues, as filing claims without proper disclosure is considered a violation of policy terms.

How Does a Pre-Existing Disease Affect Your Health Insurance

A pre-existing disease can influence your health insurance coverage in several ways, such as:

• High premiums:

When you disclose your PEDs, the insurer may charge a higher premium to account for the increased health risk.

• Waiting periods and delayed coverage:

Waiting periods differ by condition and insurer. For example, hypertension may have a waiting period of one year, while cardiac conditions may require three years. Understanding these timelines ensures you file claims only after the waiting period is completed.

• Medical screenings or health checks:

Some insurers may require you to undergo medical tests before approving coverage. These assessments help them determine your risk profile and finalise your premium, waiting period, and coverage level.

Important Things to Note About the Health Insurance Waiting Period

1. Making a claim

You cannot make any claim for any disorder that happens due to a PED. If your hypertension causes a heart attack, you won't be able to get the claim unless the waiting period is exhausted. You must inform the insurer of all your PEDs before you buy the policy to avoid any issues later.

2. Reduction by paying extra

Some insurers let you reduce the waiting period by paying an additional premium. This can be especially helpful if you want faster coverage. For example, if you have a thyroid condition and the insurer allows you to reduce the waiting period from three years to nine months by paying a little extra, opting for it can provide quicker and more complete protection.

3. Not included if recently affected

The waiting period does not apply if you develop a condition for the first time after buying the policy. For instance, if you purchase a health plan in December 2025 and receive your first-ever diabetes diagnosis in March 2026, you can file a claim right away without serving the usual waiting period for diabetes.

Conclusion

Understanding how waiting periods work is essential for assessing the extent of coverage for your pre-existing diseases. Always disclose your PEDs at the time of purchase to avoid claim rejections or policy cancellations. Since insurers have different waiting periods for PEDs, review your policy terms carefully. Most plans also offer riders that reduce these waiting periods for an additional premium. If you want faster access to PED coverage, opting for such a rider can be a practical choice.

FAQs

1. How are pre-existing medical conditions identified by insurers?

Insurers review your medical history and the documents submitted with your application. Any condition diagnosed, treated, or for which treatment was recommended within 36 months before the policy start date is classified as a pre-existing disease.

2. Which is considered one of the best health insurance plans for pre-existing conditions in India?

The right plan is one that offers favourable waiting periods, sufficient coverage, options to reduce waiting periods, and a smooth claim process. Always compare PED inclusions and exclusions before purchase.

3. Can my health insurance plan offer the shortest waiting period for pre-existing diseases?

Some plans offer shorter waiting periods, and a few even provide Day 1 PED coverage. However, this typically requires purchasing a rider or add-on and paying a higher premium.

4. What qualifies as a pre-existing disease in health insurance?

Under IRDAI rules, a PED is any ailment, injury, or condition diagnosed by a medical professional within 36 months before the policy commencement date. Conditions for which treatment was received or recommended in this period also qualify as PEDs.

5. How do health insurance plans provide coverage for pre-existing diseases?

Coverage is linked to the waiting period defined by the insurer, which may extend up to three years. For example, if hypertension has a two-year waiting period, claims can be made only after this duration.

Disclaimer The above information is for illustrative purposes only. For more details, please refer to policy wordings and prospectus before concluding the sales.

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