What Are Pre-Existing Diseases In Health Insurance?

Understanding pre-existing diseases (PEDs) in health insurance is crucial because they can affect your coverage and premiums. Pre-existing conditions, such as diabetes or heart disease, are health issues you may already have and know of before purchasing insurance. Many policies impose waiting periods before these conditions are covered or may come with higher premiums due to increased risk.

Knowing the limitations, exclusions of your policy, and how your insurance company handles pre-existing conditions will help you make informed decisions, avoid surprises, and ensure you have the necessary coverage when needed or seek an additional coverage if required.

The Coverage

• The Insurance Regulatory and Development Authority of India (Irdai) has recently revised health insurance guidelines, reducing the waiting period for PEDs from four to three years. This has made coverage for PEDs more accessible. There is no coverage for PEDs during the waiting period.

• After three years of continuous policy renewal, policyholders can generally file claims for treatment related to pre-existing conditions, provided these conditions were fully and accurately disclosed during the application process.

• Coverage for PEDs begins once the waiting period is over, but certain conditions or experimental treatments may still be excluded based on the specific terms and conditions of the policy.

Specialised Coverage

• There are riders, which can be added to the base health insurance policy, to provide coverage for PEDs.

• PED reduction riders reduce the waiting period for pre-existing conditions, typically shortening it from three to four years to around a year. Also in some cases, the coverage starts after a 30-day waiting period, depending on the policy.

• However, in case of diabetes related ailments, some policy riders provide the coverage from day one.

• Premiums for policies that cover PEDs are usually higher than that of standard health insurance policies due to the higher risk involved, although the exact amount can vary based on several factors.

Proper Disclosure Is Essential

• Policyholders must disclose any known pre-existing conditions, including diagnosed conditions, symptoms, or relevant health history at the time of filling the form to buy health insurance.

• Failure to disclose all the known medical details or ailments may result in denial of coverage or rejection of claims.

• The underwriter will evaluate the information to determine how pre-existing conditions affect coverage or claims.

• Some policies may have waiting periods before coverage for pre-existing conditions begins, which could impact the policyholder’s ability to claim benefits if something were to happen during that period. A full understanding of these terms is extremely crucial