Posted on: Dec 2, 2025 | 3 mins | Written by: HDFC ERGO Team

Health Insurance Cover for Pre-Existing Diseases Guide

Types Of Health Insurance Plans

A health insurance plan covers most of your medical expenses, including medicines, treatment procedures, diagnostic tests, surgeries, pre-hospitalisation, post-hospitalisation and more. However, when you are diagnosed with a pre-existing disease (PED), insurance providers may apply certain conditions to cover it.

This blog provides an overview of pre-existing diseases, the concept of waiting periods and tips to help you buy the right coverage.

Understanding Pre-Existing Diseases

According to the Insurance Regulatory and Development Authority of India (IRDAI), a pre-existing disease is a condition that has been diagnosed and treated within the last 36 months prior to the insurance policy commencement date. Common examples of such PEDs are diabetes, chronic blood pressure, thyroid, asthma, and arthritis.

Waiting Period for Pre-Existing Conditions

The IRDAI defines waiting period as the term during which certain diseases, illnesses, injuries and other conditions are not covered. Insurance companies provide coverage for these conditions only after the completion of the waiting periods. For pre-existing conditions, the IRDAI has amended the maximum waiting period to 3 years from 4 years. This means you cannot claim PED coverage during the waiting period and should wait until it is over to file your claims. Most insurers have a 2 to 3-year waiting period for PEDs.

Some insurers offer an add-on plan to reduce the waiting period at an increased premium.

Why Insurers Limit Coverage for Pre-Existing Diseases

Insurers are cautious when offering coverage for PEDs because individuals with existing medical conditions are more likely to file frequent claims and may face higher health risks in the future. This increases the insurer’s financial liability due to potentially large and recurring claim payouts.

To manage this risk, insurers apply certain terms and conditions to health insurance with pre-existing coverage. These typically include waiting periods, higher premiums for reducing those waiting periods, and, in some cases, exclusions for specific high-risk conditions. These measures help insurers maintain a balance between offering coverage and managing long-term claim costs.

Importance of Disclosing Pre-Existing Conditions

Disclosing your PEDs is important for the following reasons:

• Avoiding claim rejection:

Your claims can be rejected and you may be barred from further coverage if you don’t disclose your PEDs on time.

• Proper premium calculation:

Full disclosure of your PEDs gives you an accurate picture of your premiums based on your risk profile.

• Understanding the terms thoroughly:

After disclosing your PEDs, insurers provide you with a list of inclusions and exclusions under your policy, thereby helping you make an informed decision.

• Kick off waiting periods:

You must disclose your PED to insurers on time to kick off your waiting period. Ideally, the day you purchase the policy after disclosing your PEDs is day 1 of the waiting period.

Buying Health Insurance with Pre-Existing Diseases

Here are some helpful tips for you when buying health insurance with pre-existing coverage:

• 3-year maximum waiting period:

According to the new IRDAI rules, you must wait a maximum of 3 years to claim expenses on your PEDs. Certain PEDs may have a waiting period of less than 3 years as well.

• Full disclosure of PEDs:

Timely disclosure of your PEDs to your insurers is a must, as it helps you avoid policy cancellation and claim rejections.

• Long-term impact:

Insurers will consider your condition as a PED only if it has a long-term impact on your health. Minor ailments, such as the flu, fever, cold, or other issues, are not considered PEDs.

• Choose waiting periods carefully:

When purchasing family floater plans that include senior citizens, it is advisable to select plans with a low waiting period.

• Avoid policies with a co-payment clause:

Avoid buying medical insurance with co-payment clauses, as these will require you to pay a percentage of expenses out of your pocket at the time of filing claims.

Things to Know Before Choosing A Policy

Some important points to remember before choosing a medical insurance include:

• Always read the terms of the policy document to know the inclusions, exclusions, conditions related to PED coverage, co-payment clause (if any), entry age limit, eligibility criteria and more.

• Know the terms of the waiting periods of PEDs and disclose your PEDs honestly.

• Understand the rider plans for reducing waiting periods.

• Some insurers require you to get health checks done before authorising PED coverage.

Conclusion

If you have a pre-existing condition such as diabetes, high blood pressure, or arthritis, it’s important to choose a health insurance plan that offers adequate PED coverage. Carefully review the terms related to waiting periods and available rider options to ensure you receive the protection you need. Most importantly, always disclose your medical conditions honestly. Transparent disclosure not only prevents claim rejections and policy cancellations but also ensures you get the full benefits of your health insurance when you need it the most.


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


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