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What is a Pre-Existing Condition in Health Insurance?

Pre-existing conditions in health insurance refer to any disease, illness or medical condition that the policyholder has before buying the insurance policy. Pre-existing conditions are initially not covered under health plans. Coverage for pre-existing ailments is only provided once the waiting period for those specific medical conditions is over. Different insurers have different waiting periods for pre-existing illnesses. Read on to know more about pre-existing conditions in health insurance.

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An increasing number of people in India are looking to buy health insurance due to rising medical costs and higher awareness about the importance of health insurance. However, there are many aspects of health insurance that may be difficult for a layman to understand. One of these aspects is pre-existing conditions in health insurance and the waiting periods associated with them. Usually, insurance companies set a ‘waiting period’ where coverage for pre-existing diseases is not covered. Once the waiting period (usually 2-4 years) has passed, the policyholder can get coverage for their pre-existing conditions. Let’s take a more detailed look at pre-existing diseases in health insurance.

Old Definition of Pre-Existing Diseases

As per older insurance standards, pre-existing diseases (PEDs) were defined as chronic illnesses such as cancer, high blood pressure, diabetes, etc. that the potential policyholder had at the time of purchasing the health insurance policy. Further, any diseases that developed within 3 months of purchasing the insurance policy were also considered pre-existing conditions. Coverage for these conditions was not provided until the waiting periods for the pre-existing diseases had passed.

New Definition of Pre-Existing Diseases

The Insurance Regulatory and Developmental Authority of India (IRDAI) released a circular on February 10, 2020, stating that pre-existing diseases are any medical conditions, illnesses, or injuries that have been diagnosed within the last 48 months before purchasing the health insurance policy. No coverage for these pre-existing conditions would be provided till their waiting periods have passed. However, any diseases or medical conditions that are diagnosed after purchasing a health plan, even within the first 3 months would not be termed pre-existing diseases and coverage would be provided for them.

Why are Pre-Existing Diseases Not Covered in Most Insurance Plans?

The reason behind this is pretty obvious but there is a fact you must know. The harsh truth is insurance companies are for-profit businesses. So, insurance providers will be apprehensive in providing health insurance plans to people suffering from pre-existing diseases. They pose higher financial risks to insurance providers because they are likely to file a claim. Of course, it is never easy to predict a medical condition in advance. But insurers are aware or want to know if policyholders may be suffering from health issues. Thus, they set waiting periods of a few years where the pre-existing conditions are not covered. Coverage for pre-existing conditions begins once the complete waiting period has passed.

Tips to Remember When Buying Health Insurance Policy For Pre-Existing Diseases

Here are a few important tips you should keep in mind when looking for health insurance if you have pre-existing diseases:

 

  • Look for a health insurance plan that has a lower waiting period. Different insurers have different rules when it comes to waiting periods for pre-existing conditions. So, try to find a plan that offers the lowest waiting periods of all available health plans.

  • Some health plans also offer ‘add-on riders’ that you can use to lower the waiting periods on your health insurance plans.

  • If you specifically want insurance for your pre-existing disease or condition, you always have the option to wait for 48 months after diagnosis and then buy a health plan. That way, coverage for the condition will be provided to you from the moment your plan is activated.

  • Read the terms and conditions of any health policy in detail before you buy it so that you understand all the rules about coverage for pre-existing conditions.

  • It should be noted that in some cases, pre-existing diseases can lead to an increase in the cost of premiums for your health insurance plan.

  • In case you are suffering from chronic or life-threatening pre-existing conditions, the insurer may refuse to sell you a health insurance policy.

What Should you do When Buying Health Insurance for Pre-Existing Diseases?

If you are looking to buy a health insurance plan and you have pre-existing diseases, your best option is to look for a plan that has the lowest waiting periods. As mentioned above, you can also buy an ‘add-on cover’ to lower or completely remove the waiting periods on your pre-existing conditions. Ideally, you should compare all health insurance plans available by checking out their details online and analysing their rules about waiting periods, as well as other benefits and features. Most importantly, do not buy any health plan blindly without reading the policy document.

Why is it Your Responsibility to Disclose Any PEDs?

You are required to disclose any pre-existing disease at the time you buy a health insurance plan or family health insurance. 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 tenor if the illness proved to be a pre-existing disease is not disclosed when you buy the policy. They will outright reject claims to cover any costs throughout the policy term. To conclude, you can buy a health insurance plan or family health insurance if you have been diagnosed with a pre-existing disease but they will only be covered after their waiting periods are over. Different companies have different policy options. 

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FAQs on Pre-Existing Diseases

✔️Are pre-existing diseases covered under health insurance?

Initially, pre-existing diseases are not covered under a new health insurance plan. However, coverage for these conditions begins once the waiting periods have passed. 

✔️How can I lower the waiting periods for pre-existing conditions?

Some insurance providers sell special add-on covers that you can buy to reduce or remove waiting periods for pre-existing conditions in health insurance. 

✔️What is a pre-existing condition in health insurance?

As per the new guidelines by IRDAI, any disease, injury or medical condition diagnosed within 48 months before the purchase of the health plan will be considered a pre-existing condition. 

✔️How much is the waiting period for pre-existing conditions?

Different insurance companies have their own rules regarding waiting periods. Generally, waiting periods are between 2-4 years for pre-existing conditions. 

✔️How do insurance companies know about pre-existing conditions?

As per health insurance rules, you are required to disclose any pre-existing health conditions you may have to your insurer. Moreover, some insurance companies may ask you to get a health check-up at the time of buying the policy to know your current health status.