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Are Your Pre-Existing Diseases Covered by Health Insurance ?

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A health insurance policy is a smart financial decision, as it shields you from both planned and unexpected medical expenses. These policies typically cover costs related to hospitalisation, surgeries, treatments, diagnostic tests, and doctor consultations. However, if you have already been diagnosed with a pre-existing disease (PED), its coverage under a health insurance plan is subject to specific terms and conditions. This blog explains what pre-existing diseases are and how they are covered under medical insurance policies.

What is a Pre-Existing Disease

According to the Insurance Regulatory and Development Authority of India (IRDAI), a pre- existing disease is any condition, ailment, injury, or disease that was diagnosed or treated within 36 months prior to the commencement of a health insurance policy. This also includes any medical advice, treatment, or consultation received for the condition during this 36- month period.

Common examples of pre-existing diseases include diabetes, hypertension (high blood pressure), asthma, and arthritis. While many health insurance plans do cover such conditions, the coverage is generally available only after the completion of a specified waiting period, as defined in the policy terms.

Pre-Existing Diseases Waiting Period

Wondering, “What is pre-existing disease in health insurance?” It refers to the duration during which the insurer does not cover medical expenses related to your PED.

Different pre-existing conditions may have different waiting periods. However, as per IRDAI guidelines, the maximum waiting period for pre-existing diseases is capped at 36 months (3 years) from the policy commencement date.

Most health insurers in India impose a waiting period of 1 to 3 years for PEDs. Claims made for expenses related to pre-existing conditions during this time are not admissible. That said, some insurers offer the option to reduce the waiting period by opting for specific add-ons or riders, available at a higher premium, enabling earlier coverage for pre-existing diseases.

Why Do Health Insurance Companies Dislike Pre-Existing Diseases?

Health insurers are cautious about covering pre-existing diseases because individuals with existing medical conditions are more likely to require medical treatment and hospitalisation during the policy period. This increases the probability of claims and, in turn, raises the insurer’s financial risk.

To manage this higher risk, insurers adopt measures such as waiting periods, higher premiums for reducing waiting periods, and, in some cases, specific exclusions for high-risk conditions. These mechanisms help insurers balance their potential financial liability while still offering coverage for pre-existing diseases in a sustainable and regulated manner.

Why Disclose Pre-Existing Diseases To Your Insurer?

Disclosing PEDs at the time of buying a health insurance policy is essential for the following reasons:

• Smooth claim settlement

If PEDs are not disclosed accurately, insurers can reject claims and may even cancel the policy or deny future coverage for non- disclosure or misrepresentation.

• Correct premium calculation

Declaring your PEDs helps the insurer assess your risk profile and determine the appropriate premium, enabling better financial planning without surprises later.

• Clear understanding of policy terms

Disclosure allows you to clearly understand the policy’s inclusions, exclusions, waiting periods, and any condition- specific clauses before making a purchase decision.

• Timely activation of waiting periods

The PED waiting period begins from the policy commencement date, provided the condition is disclosed upfront. Early disclosure ensures that the waiting period starts on Day 1, helping you become eligible for coverage sooner.

Overall, honest and complete disclosure protects your interests and ensures uninterrupted coverage when you need it most.

Tips to Buy Health Insurance If You Have a Pre-Existing Disease

When purchasing a health insurance plan with PED coverage, keep the following points in mind to avoid surprises later:

• Read the policy document carefully

Pay close attention to key terms such as the PED waiting period, co-payment clause (if any), entry age limits, inclusions, exclusions, sub-limits, and overall coverage conditions.

• Disclose all PEDs honestly and upfront

Never skip or delay PED disclosure. Non-disclosure can lead to claim rejection or policy cancellation. Also, check the specific waiting period applicable to each disclosed PED.

• Check options to reduce the waiting period

Some insurers offer riders or add-ons that allow you to shorten the PED waiting period in exchange for a higher premium.

• Understand pre-policy requirements

Certain health plans may require medical tests or screenings before offering coverage for PEDs. Review these requirements in advance to avoid delays in policy issuance.

Things to Know About Pre-Existing Conditions in Health Insurance

If you are planning to buy a health insurance policy with PED coverage, be aware of these important aspects:

• Maximum waiting period of 3 years

As per IRDAI guidelines, insurers cannot impose a PED waiting period of more than 36 months (3 years). Some conditions may have shorter waiting periods, typically 2 years.

• PED disclosure

Honest and complete disclosure of pre-existing conditions at the proposal stage is compulsory. This helps you choose a plan that aligns with your medical needs and ensures smoother claim settlement.

• What qualifies as a PED

Insurers generally classify conditions with a long- term or chronic impact, such as diabetes or hypertension, as PEDs. Short-term illnesses like the flu, cold, or viral infections are not considered pre-existing diseases.

• Age of the insured

If you opt for a family floater plan that includes senior citizens, check the PED waiting periods carefully. Plans designed for older members often have longer waiting periods or co-payment clauses.

• Co-payment and deductible clauses

Some policies require you to bear a portion of the medical expenses through co-payments or deductibles. Compare plans carefully and opt for policies with low or zero co-payment, especially if you have ongoing medical needs.

Conclusion

Evaluate your medical history carefully and choose a health insurance plan that offers suitable coverage for pre-existing conditions such as arthritis, hypertension, diabetes, and other chronic conditions. Make it a priority to read the policy document in detail and understand key aspects like PED waiting periods, exclusions, and available riders that may help enhance or accelerate coverage when purchasing health insurance online. Most importantly, disclose all pre-existing conditions honestly at the time of purchasing the policy to prevent claim rejections and ensure you receive timely and reliable coverage when you need it 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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