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Health Insurance Pre-Existing Conditions

IRDAI Rules for Pre-Existing Diseases Cover

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About Pre-Existing Disease Cover Health Insurance

Health is wealth, indeed. However, it faces many risks due to several factors - right from lifestyle to family history – giving rise to ailments. Keeping a regular check on health is the best way to keep diseases at bay. Nevertheless, a medical emergency is among the uncertainties for which we must be financially prepared. Investing in health insurance gives you a shield that will prevent your savings from draining out during unforeseen events like a planned surgery or emergency hospitalization. However, those with pre-existing diseases (PED) need to be aware of the crucial fact that one cannot get coverage under health insurance for pre-existing diseases right from day one. There is a waiting period in health insurance plans, a specified time the insured must wait before getting a claim for such ailments. 

However, they can rest assured that they can get coverage under the best health insurance policy once the waiting period is over. Let us discuss the pre-existing conditions and things to keep in mind when selecting health insurance with pre-existing disease cover.

What are Health Insurance Pre-Existing Conditions?

Pre-existing conditions in health insurance refer to any health problem, such as an illness, injury, or other medical conditions, that the insured was facing within 48 months before the date the policy was issued. Some common examples of PED include diabetes, hypertension, thyroid, COPD, cancer, and sleep apnea.

IRDAI Announcements on Health Insurance Pre-Existing Conditions

According to a circular issued in February 2020, the definition of "health insurance pre-existing conditions" was changed and modified.

Let's read about health insurance pre-existing diseases, the new amendment by IRDAI, and how it is beneficial for policyholders having a pre-existing disease.

Health Insurance Pre-Existing Conditions Old vs New

Below is the difference between the old and the new definition of pre-existing diseases:

Old Definition of Pre-Existing Diseases

New Definition of Pre-Existing Diseases

That was diagnosed by any physician within 48 months, before the effective date of the policy issuance.

That was diagnosed by any physician within 48 months, before the effective date of the policy issuance.

Any medical condition for which medical advice or any treatment was received from any physician within a 48-month duration prior to the effective date of the policy or its reinstatement.

Any medical condition for which medical advice or treatment was recommended, or received from, a physician within a 48-month duration prior to the effective date of the policy issued by the insurer or its reinstatement.

Any condition for which symptoms/ signs if presented and have resulted within three months of the policy issuance in a diagnostic illness or medical condition.

According to the amendment, this clause has been deleted.

Therefore, according to the new amendment, no disease or illness shall be considered as a pre-existing disease if diagnosed within three months from the date of buying the policy.

Note: However, the modification in health insurance pre-existing conditions is not applicable to travel insurance.

How are the IRDAI Guidelines on Health Insurance Pre-Existing Conditions Beneficial for Policyholders?

The IRDAI guidelines will benefit a policyholder in the following ways:

  • It will significantly reduce the claim rejection rates 
  • It takes away most of the ambiguities in pre-existing diseases
  • The instances of insured not disclosing the true medical history will reduce and they will get claim without facing claim rejection

Health insurance has now become a necessity. Earlier, it was difficult for people with pre-existing conditions to get complete coverage as there were chances of claim rejection or an increase in the waiting period. The IRDAI guidelines are beneficial for people who could not afford the on-going treatment of their pre-existing disease and had to face claim rejection. After the amendment, even if they are diagnosed with such chronic diseases after buying a policy, they will get a claim, subject to policy terms and conditions.

Trusted brands like Care Health Insurance (formerly Religare Health Insurance) offer cashless health insurance plans to people with pre-existing diseases so that they can avail the best possible treatment without worrying about arranging money to pay the hospital bills.

Things to Remember if you Have a Pre-Existing Medical Condition

You can get a health insurance cover even if you have a pre-existing medical condition without worrying whether the insurer will reject your proposal. However, keeping some facts in mind will keep you well-informed and help you get the best health insurance for pre-existing disease:

  • Identify pre-existing diseases: Minor health issues, such as cough, cold, and fever, are not pre-existing diseases. Not every ailment is a pre-existing disease. There is a list of pre-existing conditions admissible for the claim under the health insurance coverage, subject to a waiting period. 
  • Disclose complete information: Never hide your medical condition that may affect your chances of getting a health insurance policy or lead to claim rejection if any pre-existing condition is found later. 
  • Pre-policy medical check-up: In some cases, a policy buyer may have to go for a pre-policy medical check-up, as per the underwriter's discretion.
  • Waiting Period: Any health insurance plan with pre-existing disease cover has a waiting period, usually 48 months. Look for health insurance plans with a low waiting period so that your pre-existing illness gets covered at the earliest. You can also opt for a reduction in the waiting period for pre-existing diseases as an add-on benefit at an additional premium.  
  • Premium: The health insurance premium, due to pre-existing disease, will be on the higher side. It is so because we are taking the risk of covering a pre-existing illness. 

 

It is in your best interest if you go for a health insurance policy at a young age so that the possibility of having any pre-existing condition is low. If you have a pre-existing ailment, you must wait through the applicable waiting period to avail the coverage when any illness develops.

FAQs

How are pre-existing conditions determined?

The diseases, injury, and other medical conditions that existed before the policy issuance are known as pre-existing conditions. These are diagnosed by any physician within 48 months, before the effective date of the policy issuance.

Can I be denied health insurance if I have a pre-existing condition?

You can get a policy even if you have a pre-existing medical condition. However, underwriting of claims for pre-existing diseases is subject to policy terms and conditions. 

Could my health plan have a pre-existing condition waiting period?

Yes, your health plan has a pre-existing condition waiting period. However, you can choose a reduction in the waiting period add-on cover. The waiting period will be reduced from 48 months to 24 months , subject to policy terms and conditions.

What if I am aware of a pre-existing ailment and do not disclose it? 

It is of utmost importance to furnish complete details about your medical history, including any pre-existing disease, when buying health insurance. If you were aware of your pre-existing ailment but do not disclose it to the insurer, you are most likely to face a claim rejection if you get hospitalized for treating the condition. It is so because there is a waiting period applicable for pre-existing ailments, and the policyholder cannot get a claim during this period.

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

There is no impact on the amount of coverage one can get for a pre-existing ailment. However, there is a waiting period the policyholder must wait before getting the claim. Also, a pre-existing disease in health insurance is a factor that will impact the cost of your premium. The premium will be higher for those who have a pre-existing ailment or a medical condition.

How do I buy health insurance for parents who have pre-existing ailments? 

If your parents have a pre-existing medical condition, there are a few things that you need to consider before you pick the right health cover.

  • Waiting Period: In India, it is impossible to find health insurance for pre-existing conditions with no waiting period. Any medical insurance option you choose for your parents will have a waiting period, usually 48 months, for pre-existing diseases. Before finalizing a health insurance option, ensure that you have selected the one with a minimum waiting period. 
  • Sum Insured: When is a chance of emergency hospitalization or medical treatment arising due to the pre-existing condition; it is wise to go for a higher sum insured. One should also consider medical inflation and the high costs of surgeries before selecting an adequate sum insured option. 
  • Medical check-up: It is possible to get a health cover online for parents without pre-policy medical tests. In some cases, however, one may have to go through a medical test at the discretion of the underwriter.
  • Affordable Premium: It is more likely that the health insurance for your parents will have a marginally higher premium than for someone without a pre-existing condition. However, you will be able to find an affordable option after careful comparison and review of various plans.
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