Does Health Insurance Cover Genetic Disorders in India?

A genetic disorder is a disease caused by an abnormality in a person's genome, i.e., their genetic material. Previously, individuals with genetic diseases faced challenges in obtaining health coverage. However, as per the recent guidelines of the Insurance Regulatory and Development Authority of India (IRDAI), genetic diseases or disorders will no longer be excluded from health insurance policies.

Health insurance companies will now cover genetic disorders under a standard health insurance policy. It is a significant move, especially since getting health insurance for congenital diseases and genetic disorders in India will now be possible. It enables individuals to access quality medical care without worrying about the expenses.

Genetic Disorders: No Longer a Part of Exclusions

According to the guidelines issued in September 2019 under the Standardisation of Exclusions in Health Insurance Contracts, the IRDAI has standardised the wording of exclusions.

The treatment of internal congenital diseases, genetic diseases or disorders, mental illness, neurodegenerative disorders, puberty, and menopause-related disorders will now fall under the scope of health insurance plans.

Also, the usage of drugs, stimulants or depressants prescribed by a medical practitioner will become a part of health insurance coverage.

Truth About Coverage of Genetic Disorders

Prince, a marketing professional, was diagnosed with a genetic disorder and was worried about the treatment cost, constantly thinking, “Does insurance cover genetic testing?”

But as he scanned through the policy documents, he realised that genetics is a broad term, and not all conditions are treated equally.

• Coverage for genetic disorders isn’t universal. It means that the coverage of genetic disorders in health insurance depends on the policy terms, the insurer’s guidelines, and exclusions.
• It is a myth that genetic disorders are fully covered because of court rulings. Insurance claims for genetic disorders are subject to policy terms and conditions.
• Not all chronic or inherited conditions are automatically covered.

You can think of ot this way: Insurance coverage for genetic testing is not one-size-fits-all. It lies in the details of the insurer’s terms, waiting periods and exclusions that shape the health coverage.

>> Read More: How can Genetic Testing help Identify Genetic Disorders?

Key Checks Before Buying Genetic Disorder Health Insurance

While genetic disorders can no longer be excluded outright (as per IRDAI’s directive), not all policies offer the same level of financial protection. Here’s what you need to review carefully:

1. Exclusions Beyond the Basics

Some insurers may exclude advanced or experimental treatments

For instance, a policy might cover blood transfusions for Thalassemia patients but exclude advanced procedures such as bone marrow transplants. Gene therapy, which is still emerging and costly, is usually excluded from most health insurance plans.

2. Pre-existing Condition Clauses

Since many congenital and genetic diseases are identified early, insurers usually classify them as pre-existing conditions. What to look for:

• Does the insurer define them as a pre-existing condition?
• Do they become eligible for coverage once the waiting period is over? Does the medical policy list any permanent exclusions?

3. Waiting Periods

• Initial waiting period: 30 days
• Named Ailments: 24 months
• Pre-existing conditions: 36 months

However, you can reduce the waiting period with add-ons, such as Instant Cover or PED Modification. With the help of these add-ons, you can reduce the waiting period to 30 days and 1 or 2 years, respectively.

4. Coverage for Genetic Testing?

Many people often wonder: Is genetic disease covered by insurance, and will insurance cover genetic testing?

So, the answer is that genetic disorders often require specialised diagnostic tests such as DNA sequencing, genetic screening, or enzyme testing. , all of which can be expensive, and coverage may vary.

• Check if genetic diagnostic tests are covered under the policy.
• See if there is a financial cap. Verify whether advanced treatment, such as stem cell therapy, is covered under the policy.
• If multiple family members are at risk of hereditary conditions, family health insurance can be a wise choice that covers their genetic testing under a single shared policy.

What Does the Future Look Like?

India’s health insurance industry is undergoing a rapid transformation, as evidenced by the following regulatory updates:

• Over 70 million people in India live with rare diseases. =
• Breakthroughs in biotechnology, gene therapies, and personalised medicines may soon expand advanced treatment options.
• IRDAI (Insurance Regulatory and Development Authority of India) is consistently refining its guidelines, bringing stronger protections and fairer clauses for policyholders.
• Growing Awareness about genetic disorders is creating a stronger push for more inclusive health insurance coverage.

The bottom line is that the future looks promising with IRDAI Reforms and advancing therapies; policyholders can expect broader coverage for genetic conditions.

Why Health Coverage Matters for Individuals with Genetic Conditions?

In today’s world, where even genetic disorders like diabetes, heart disease, and certain rare conditions can unexpectedly impact lives, health insurance is more than just a financial tool; it’s a form of preparedness.

• Cashless treatment offers greater ease and comfort.
• Shield your hard-earned savings against expensive medical treatments.
• Guarantees uninterrupted access to medical support in times of medical emergencies.

Thanks to updated policies, patients with congenital and genetic disorders can now safeguard both their health and financial well-being.

Disclaimer: All plan features, benefits, coverage and claims underwriting are subject to policy terms and conditions. Kindly refer to the brochure, sales prospectus and policy documents carefully.