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Pre-Existing Disease Health Insurance

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Pre-Existing Disease Health Insurance
January 09, 2024

Table of Content

 

People are experiencing health difficulties at a young age as a result of their changing lifestyle. Poor nutrition and a lack of exercise are common causes of these problems. For example, keeping a healthy Body Mass Index (BMI) is critical for avoiding certain health concerns. Use the BMI Calculator to see where you stand on the BMI scale.

Medical expenditures for treating health issues are also increasing dramatically. As a result, it is becoming increasingly difficult for the middle class to cover these costs solely from their life savings.

To address this issue, one can see the importance of purchasing a detailed health insurance plan. Purchasing a pre-existing disease health insurance while there is time, can help you and your loved ones in many ways. 

To know the importance of health insurance for pre-existing diseases, read till the end. 

What is a Pre-existing Disease in Health Insurance?

As per the Insurance Regulatory and Development Authority of India (IRDAI), any health conditions, sickness or injuries that a person is undergoing before purchasing a health insurance policy is a pre-existing disease. 

Health insurance covers some of these pre-existing diseases under certain terms and conditions. You can claim reimbursement for pre-existing diseases in health insurance after completing a certain waiting period.

What Is a Pre-existing Illness?

When an insured individual is suffering from a particular illness or any medical condition before purchasing health insurance, it is called a pre-existing disease (PED). IRDAI categorises a medical condition as a pre-existing illness if the person has been suffering it for more than 4 years from the date of purchasing or renewing a policy. 

Chronic diseases or long-term health conditions like cancer, heart conditions, asthma, COPD, thyroid, high blood pressure and diabetes are considered pre-existing diseases.

Pre-Existing Diseases Old Definition

According to the old definition of pre-existing diseases, they include health conditions like cancer, diabetes and high blood pressure at the time of purchasing a health insurance policy. It also covered instances of symptoms of these health conditions if they appear three months after the purchase. Moreover, if any ailment requires treatment within 48 hours of buying health insurance, it is also considered a pre-existing disease. 

However, health insurance policies do not cover any of these conditions. In other words, if a person is suffering from any disease mentioned in the above definition, they cannot claim insurance benefits for a long time. The policy’s waiting period determines when the policyholder would be able to get coverage for the PED. This could take anywhere from six months to four years. 

This definition acted as a disadvantage for individuals and impacted the purchase of health insurance in India. It led to insurers rejecting claim requests for any kind of pre-existing chronic disease as its treatment involved complicated surgeries and tests. 

What Is Health Insurance For Pre-Existing Conditions? 

With time, the definition of health insurance for pre-existing conditions was updated. As per a circular published by IRDAI in February 2020, any medical condition that a person is diagnosed with before purchasing a health insurance policy falls under pre-existing conditions. It also covers any medical conditions diagnosed within 48 months of purchasing a health insurance plan. 

This new definition acted as a game changer for health insurance plans in India and helped re-establish its lost glory. It reduced claim rejection rates of insurers and encouraged more people to get health insurance coverage. Today, health insurance for pre-existing conditions covers chronic diseases diagnosed within a few months of purchasing a policy. 

The new definition only considers those chronic diseases that are diagnosed and recorded before buying a policy as PED. In case any disease that you were unaware of got diagnosed after the health insurance policy came into effect, it would not be classified as PED. 

Unlike the old policies, with the new amendments, policyholders would no longer have to wait for a long period to file health insurance claims. 

Factors to Consider When Buying Health Insurance for Pre-existing Diseases

Here are certain factors you must consider before buying health insurance for pre-existing disease:

  • You Can Choose to Waive the Waiting Period

    This factor can vary between insurance companies. Certain insurance companies can offer the option to omit the waiting period clause for a pre-existing illness in exchange for an extra premium. The insurer can reduce or remove the waiting period duration if you opt for this option.
    However, there’s a catch; insurers provide this option depending on the severity of your illness. Also, if your illness has advanced to a critical stage, the insurer might not propose this offer.

  • All Health Insurance Policies Do Not Cover Pre-existing Diseases

    Pre-existing health conditions are not available for all policies. Therefore, before purchasing one, you must read the terms and conditions thoroughly. This will help you know about chronic and pre-existing diseases that this health insurance plan covers. You must confirm these details with your insurance provider and plan your purchase accordingly.

  • Disclose Your Pre-existing Illness Before Buying a Policy

    Providing wrong information or hiding medical details can lead to complications and rejection of your claim request. Therefore, every individual must maintain transparency and provide their medical details to the insurer at the time of buying a health insurance plan.

  • Pre-existing Illnesses Can Affect Policy Premiums

    If you are undergoing treatment, your health insurance premium will be higher compared to insurance plans without pre-existing illnesses. Regardless of this, you must never hide your health history from the insurance company while purchasing a plan to avoid any form of complications while filing insurance claims.

  • The Terms and Conditions of a Health Insurance Policy

    The terms and conditions of health insurance include the screening period, list of pre-existing illnesses and waiting period. These terms vary among different policies. Often, insurance providers will ask you to undergo specific medical check-ups before providing the policy.
    While some insurers might seek to know your medical history before offering a policy, the terms and conditions of each will be different. Therefore, consider reading through them thoroughly before making a purchase. 

Effects of a Pre-existing Disease on Your Health Insurance

After disclosing your pre-existing health condition to your insurer, your health insurance policy may have the following effects:

  • Premium Loading

    In some instances, you can get instant coverage for pre-existing diseases for a comparatively higher premium. This amount will be added to your premium to cover treatments and medicines for pre-existing conditions.
    With a higher premium, you can be assured that your insurance will cover all expenses such as lengthy hospitalisation procedures and further health complications from your illness. However, this facility is not available to individuals reporting any disease that occurs after purchasing this plan. 

  • Waiting Period

    In some cases, insurers may cover your pre-existing disease at the same premium only after completion of the waiting period. This period can vary among insurance providers and diseases or their complications. During this time, your insurance company will not cover expenses related to any kind of hospitalisation or medications associated with your pre-existing disease. 

  • Policy Denial

    The insurance company may reject your application to purchase a health insurance plan with them to cover a pre-existing health condition. 

  • Premium Loading + Waiting Period

    In a few instances, your insurance company might charge a higher premium after the waiting period to cover your pre-existing illness with health insurance. Such a situation usually arises with chronic illnesses like hypertension. 

  • Permanent Exclusion

    Under this, the insurance company might provide you with coverage but will not include your pre-existing illness. Thus, the health insurance policy will cover medical expenses except those associated with your pre-existing condition. 

  • Medical Checkup

    After disclosing your pre-existing health condition, your insurance company might require you to undergo certain diagnostic tests. Based on these test results, they will offer you a policy to cover the medical needs associated with your health condition. 

Pre-existing Diseases Waiting Time

Certain health insurance policies provide a predefined time span, after which, the health insurance plan will bear the expense of selective pre-existing diseases. However, according to IRDAI, these diseases will be considered only if you report them at the time of purchasing the insurance.

The waiting time for pre-existing diseases health insurance might vary from one insurer to another depending on factors like your age, pre-existing medical conditions and your health insurance premium. However, the general waiting time for pre-existing disease health insurance is 2 to 4 years.  

Types of Waiting Periods under Health Insurance Plans 

A health insurance plan can have several types of waiting periods. The points below highlight some of the important periods in detail. 

  • Initial Waiting Period

    This waiting period is available for most health insurance plans. To file a claim, a person must wait for a specific period after purchasing the insurance policy. This is the initial waiting period which can range from 1 month to 90 days.
    Insurers will only make an exception for accidental claims during this waiting period. They will approve a person's claim request in case of an accident that requires immediate medical attention.

  • Maternity Waiting Period

    Certain health insurance policies for families and individuals offer an add-on facility to cover maternity medical expenses. To claim this health insurance coverage, a person must complete a waiting period of two years to four years.
    On this note, you might also come across health insurance that allows a lesser time span as a waiting period. However, such insurers might charge a higher premium in exchange.

  • Waiting Period for Pre-Existing Diseases

    This is a special waiting period after which a person can get claims settled for medical expenses related to health conditions diagnosed before buying that insurance. As per the IRDAI definition, any injury or illness diagnosed 48 months before purchasing the insurance is a pre-existing health condition. The waiting period for this type of insurance can vary based on your ailment and its complexity among insurers.

  • Waiting Period for Specific Diseases

    Many health insurers stipulate different waiting period clauses for different diseases. Ailments like COVID-19, ENT disorder, tumours, cardiac issues, stroke and many more have specific waiting periods assigned to them. This can again vary among insurers and you can find it in the policy details provided to you.

Why Do Health Insurance Companies Not Prefer Pre-Existing Diseases?

Very often as a buyer, you might feel a note of apprehension from issuers’ end while purchasing health insurance with pre-existing disease coverage. This happens mainly because such insured individuals are more likely to file claims than regular policyholders. People already suffering from a major health problem have a greater probability of requesting a claim. This tends to impose a major financial risk on health insurance providers. 

However, nowadays, many insurers provide specific policies catered toward individuals with pre-existing conditions. These often provide a higher sum insured for the PED to cover disease-related complications. 

Do’s and Don'ts in Case of Pre-existing Diseases

Let’s take you through a few important dos and don’ts you must follow to opt for pre-existing disease health insurance.

Do’s

Don’ts

Consider sharing your medical history and required information on your health condition with the issuer in detail. 

Avoid hiding any information regarding your medical health. 

Get a health check-up voluntarily to know about any existing disease and take timely action.

Do not buy a health insurance plan without a comparative analysis

What Should You Do When Buying Pre-Existing Disease Health Insurance?

Here are a few points you must note to buy the right pre-existing disease health insurance plan for you and your family. 

  • Be Transparent and Honest

    Do not hide any details about your medical health or any pre-existing health issue while purchasing health insurance. By disclosing your health-related information, you can lower the chances of your claims getting rejected which can happen in alternative scenarios.

  • Choose a Plan with a Lower PED Waiting Period

    Every health insurance plan offering pre-existing disease insurance comes with a waiting period that can vary among insurers. This can also vary on the severity of your ailment. Therefore, consider conducting a comparative analysis and opt for a plan with a low PED waiting period.

  • Not All Doctor Visits Fall Under Pre-Existing Disease

    Insurers would consider ailments that can affect you, your family and your finances in the long run as pre-existing diseases.
    Pre-existing illnesses usually include chronic and/or critical illnesses. So medication for illnesses like flu, cold or cough will not be considered by them as long as they do not have any long-term side effects. 

Conclusion

To conclude, every policy buyer needs to disclose details about their or their family member's medical history while opting for health insurance. This will help them successfully get claims on pre-existing disease health insurance for elaborate medical expenses of specific ailments when required. Hiding this information can lead to the rejection of claims complicating a person's financial burden. 

FAQs on Health Insurance and Pre-Existing Conditions

Q. How are pre-existing conditions determined?

Pre-existing conditions according to IRDAI are those health issues that are diagnosed within 48 months after buying a health insurance policy. 

Q. Does a pre-existing illness have any impact on the amount of coverage?

Yes, a pre-existing illness and its complexity can tend to impact your coverage amount and premium. 

Q. What are pre-existing diseases (PED) in health insurance?

Any long-term illness like cancer, diabetes or heart issue which is diagnosed 48 months before purchasing health insurance is considered a pre-existing illness. 

 Q. What is the waiting period for pre-existing disease in health insurance?

The waiting period for pre-existing illness in health insurance can vary depending on the ailment and its complexity. The period can also vary from one insurer to another ranging from 1 to 4 years. 

Q. Can I be denied health insurance because of a pre-existing condition in India?

In cases of non-disclosure about an illness, health insurance companies can deny insurance claims you have filed in India. 

 Q. What is a pre-existing disease before 48 months?

If you are diagnosed with an illness 48 months or more before buying health insurance, the ailment becomes a pre-existing disease. 

Q. What is a serious pre-existing condition?

Conditions like high blood pressure, diabetes, asthma, etc., are some serious pre-existing diseases.

ARN: MC/12/23/7133

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Francis Rodrigues Francis Rodrigues

Francis Rodrigues has a decade long experience in the insurance sector, and as SVP, E-Commerce and Digital Marketing, HDFC Life, manages the online sales channel, as well as digital and performance marketing. He has had hands-on experience in setting up sales channels and functional teams from scratch over a career spanning 2 decades.

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Vishal Subharwal Vishal Subharwal

Vishal Subharwal heads the Strategy, Marketing, E-Commerce, Digital Business & Sustainability initiatives at HDFC Life. He is responsible for crafting and ensuring successful implementation of the overall organisation strategy.

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