How Pre-Existing Conditions Shape Your Health Insurance Coverage

A pre-existing disease (PED) is any condition diagnosed or treated before obtaining health insurance. In India, the Insurance Regulatory and Development Authority (Irdai) defines it as any illness identified within 48 months before a policy’s start date. This label often determines when and how coverage begins, creating barriers for many seeking financial security.

“Traditionally, claims for PEDs required a waiting period of up to four years. Thankfully, IRDAI’s recent reforms slash this to three years starting April 2024. While a three-year wait is still long, it signals progress. Some insurers even offer to reduce this period further through add-ons or higher premiums, a move that, while pragmatic, raises questions about equity in access,” says Bhaskar Nerurkar, head- health administration team, Bajaj Allianz General Insurance. 

The fine print often hides sub-limits and co-payment clauses for PED claims, forcing policyholders to shoulder part of the financial burden. This adds another layer of complexity, urging consumers to scrutinize policy terms meticulously.

“Some insurers even offer to reduce this period further through add-ons or higher premiums, a move that, while pragmatic, raises questions about equity in access,” says Sundaram Varadan, secretary, the Insurance Brokers Association of India (IBAI). 

The Consequences Not Disclosing Pre-Existing Diseases 

“If a policyholder unintentionally fails to disclose a pre-existing condition, the consequences vary by insurer. Insurers require accurate information for underwriting, as pre-existing conditions impact risk assessment. The omission may lead to a claim denial, policy cancellation, or non-renewal. Some insurers may allow time to correct the omission or reinstate coverage with adjusted premiums,” says Nerukar. To avoid issues, policyholders should thoroughly review their applications and seek clarification or professional advice as needed.

However, when applying for health insurance, insurers typically ask for a detailed medical history, including any illnesses, surgeries, or treatments from the past. It is essential to answer these questions truthfully. In some cases, the insurer may request medical tests or reports to verify the pre-existing conditions. “Even if you feel your condition is under control with medication or treatment, it is still considered a pre-existing disease and must be disclosed. Additionally, insurers may provide policyholders with specific add-ons or riders to cover pre-existing conditions after the waiting period, making full disclosure even more important,” says Nerukar.

The Onus Is On The Policyholder 

“The system still prioritizes scrutiny over trust, forcing policyholders to navigate labyrinthine clauses. The Irdai reforms are steps forward, but true progress lies in simplifying processes and ensuring inclusivity for all,” says Varadan. 

There is also a loading on premium for PEDs.  Sublimits and copayment are generally the last resort for insurers. They straight away either load the premium, have a three-year waiting period, or exclude the PED permanently. These conditions are in the schedule of the policy and also in the wording.