Pre-existing disease (PED) is an important factor to consider when you are purchasing health insurance. Understanding its implications will give you an idea about the conditions under which you can get cover for these diseases, the waiting period and how to reduce it.
By knowing how a pre-existing disease can affect your health inurance premium, you can ensure you get a holistic cover and reduce your out-of-pocket expenses when availing medical treatment.
Do not mistake pre-existing disease as an illness you have when you first buy a health policy. The definition of a pre-existing disease is complex, extensive, and recently amended. Here is the list of the most common PEDs considered by health insurance:
Asthma
Atherosclerosis
Cancer
Chronic obstructive pulmonary disease or COPD
Diabetes
High blood pressure
Lupus
Sleep apnoea
Thyroid
Read on to learn more about pre-existing diseases in health insurance.
Important Update (Dated May 30, 2024) – Good news for Health Insurance policyholders! According to the Master Circular on Health Insurance Business 29052024 rolled out on May 29, 2024 by IRDAI, insurers are to decide on the request for cashless claims within 1 hour of receiving the request. Also, the final claim is to be granted within 3 hours after the policyholder’s discharge from the hospital. Insurers have been directed by IRDAI to establish necessary systems and procedures for this process by July 31, 2024.
The Master Circular on Health Insurance Business 29052024 circular is available here - https://irdai.gov.in/document-detail?documentId=4942918
Prior to the amendment in 2020 made by the insurance regulatory body of India, the definition of pre-existing disease referred to chronic conditions that you may have been diagnosed with within 2 years prior to purchasing the policy. The definition also included chronic conditions that were diagnosed within 3 months of buying the insurance policy.
This meant that if you had a health condition before purchasing insurance or were diagnosed within 3 months of the purchase of a health plan, you could not file a claim for treatment of that condition.
The insurer would be liable cover that condition only after the waiting period for it is over. Examples of common chronic pre-existing diseases include diabetes, high blood pressure, asthma, thyroid, and others.
In addition to the above terms, any condition requiring specific treatment from a doctor within 48 months from the purchase date of a policy would also qualify under a pre-existing disease.
Under the above terms and definitions, health insurance providers could reject your claim requests if you had a pre-existing disease. This resulted in hesitance what it came to buying health insurance or misrepresentation of information.
The IRDAI issued a circular in 2020 that amended the definition of a pre-existing disease. Under the new definition, any conditions diagnosed 48 months before purchasing the insurance policy would fall under pre-existing diseases. These could include any disease, illness or injury.
Under this new definition, the previous terms are no longer applicable. This has served new policyholders well as you no longer need to worry about illnesses that you were not aware of or had not been diagnosed with.
This has resulted in a higher health insurance claim settlement for those who have discovered pre-existing conditions after the purchase of health insurance. It has also resulted in people representing their medical history accurately.
This new definition also saves you from the waiting period you otherwise would have to go through if a health condition was diagnosed as per the old definition. Given that the costs of treating chronic conditions that generally come under pre-existing diseases are high, this new definition allows you to enjoy great financial support.
Do keep in mind that the insurance providers will impose a waiting period for pre-existing disease that qualify under the new definition. In this case, you would have to complete the waiting period before filing a claim for the treatment of the diagnosed condition.
The good news is that you can buy a extra health insurance rider that helps to reduce or waive off this waiting period for a pre-existing disease so that you can get cover for related medical expenses.
Bajaj Allianz Extra Care |
Aditya Birla Activ Assure Diamond |
Care Health Insurance Plan |
|
Features |
Cashless claim, tailor-made plans, tax benefits, daily cash benefit |
HealthReturns of premiums, 586 day care treatments, annual health check-ups, worldwide assistance |
Extensive network hospitals, quick claim process, multiple insurance plans |
Claim Settlement ratio |
98.61% |
99.36% |
100% |
Premium amount |
₹2194 |
₹3887 |
₹5277 |
Disclaimer: The premiums and features mentioned are indicative and may change depending on your coverage and other factors.
If you have condition that qualifies as a pre-existing disease, you may require frequent treatment, resulting in frequent claims. This makes the insurer liable to cover such claims and increases their financial risk.
Due to this, insurers look to reduce their liability by assessing your personal and family medical history to understand your overall health. The risk of pre-existing diseases these days can be covered by a higher premium or by you choosing to buy an add-on to reduce the waiting period.
Even if you have a pre-existing disease, you can get health insurance. There are many policies that have a PED cover. All you need to do is know what the screening process and waiting period is. This will allow you to choose the right health plan that covers pre-existing diseases.
Some policies cover a pre-existing disease from the very beginning, while others may have a waiting period of 1-4 years before you can make a claim for medical bills related to a pre-existing disease. During this time, you cannot file a claim for the treatment expenses of your PED.
Any claim made to cover the specified diseases during this period will be rejected.
This means doctors’ fees, medicine costs, and hospitalization to treat PEDs are not covered until after the waiting period ends.
However, there is a way for you tackle the waiting period too. There are some add-ons like a pre-existing disease buyback rider that allows you to bring the waiting period down from 4 years to just a year.
The health insurance policies on Bajaj Markets come with waiting periods of 3 years for PEDs, which is low when compared to the general 4-year waiting period in other policies.
Bear in mind that every insurance company has their own set of guidelines when it comes to claims made for a pre-existing disease. So, read your policy’s terms and conditions carefully to know what’s included and when.
You are required to disclose any pre-existing disease when you purchase an individual health insurance plan or a family health insurance policy. If you refrain from disclosing it, then the PED diagnosis will be considered a non-disclosure/misrepresentation/non-declaration.
Your claim will formally be considered a violation of the “disclosure of information norm.” The insurer can refuse to cover any disease during the policy tenure if the illness is proved to be a pre-existing disease not disclosed when you buy the policy. The insurance provider will then reject any and all claims for the treatment costs of the PED during the policy term.
To conclude, you can buy a health policy for yourself or family health insurance if you have been diagnosed with a pre-existing disease. Different companies have different policy options that offer coverage for pre-existing diseases. Make sure you disclose any past health issues and understand the waiting periods of different providers. This will help you choose the right plan. With due diligence, you can ensure that you get the best health cover.
No, the coverage for pre-existing diseases is at the discretion of the insurance provider. You can check what is included and excluded by reading through the policy document or by contacting customer support.
Yes, there are certain mental illnesses that qualify as a pre-existing disease.
Yes, you can buy health insurance even if you have a pre-existing disease. You can even get a pre-existing illness cover or rider to reduce the waiting period.
Yes, some insurers have a rider you can purchase to reduce the waiting period for a pre-existing disease. In other cases, you can choose a policy with a shorter waiting period to cover PED.
Yes, the coverage for pre-existing disease is offered at the discretion of the insurance provider. As such, they may deny offering cover for PED as per their terms related to honestly disclosing the condition and the waiting period.