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IRDA Announced Modifications in Pre-existing Diseases Rules in Health insurance

In a recent announcement, IRDA offers changes in pre-existing disease clauses in order to benefit the policyholders. The Insurance Regulator and Development Authority of India (IRDAI) has advised the health insurance companies and Third Party Administrators (TPA) to make the changes with immediate effect.

The move to amend the definition of pre-existing illnesses in health insurance is to bring simplicity and to make medical insurance in India more customer-friendly.

IRDAI released a circular mentioning the removal of ‘the additional/modified clause’ from the existing description of pre-existing illnesses. This move can actually reduce the health insurance rate of rejection in the future.

In September 2019, IRDAI stated in its circular the inclusion of certain illnesses under medical insurance policy. As per the September circular, certain illnesses that were diagnosed within a span of 3 months of the policy issuance would be considered as pre-existing illnesses and would be covered under the medical insurance policy.

However, in one of their latest circulars dated February 10, 2020, the Insurance Regulator specifies that any disease that has been diagnosed within 6 months of the policy issuance will not be treated as pre-existing diseases. IRDAI also mentioned that these modifications will also be included in the guidelines on standardization in medical insurance policies.

Basically, pre-existing illnesses refer to medical conditions or injury at the time of policy purchase. Health conditions such as blood pressure, diabetes, depression, lupus, epilepsy, sleep apnea, anxiety are called as pre-existing medical conditions.

The insurance regulator also modified the current definitions of pre-exiting illnesses, which are not applicable to international travel insurance. Below are the modifications that follow in the guidelines on the standardization of Exclusions in Health Insurance:

Existing

New

Pre-existing Disease means any condition, ailment, injury or disease:

Pre-existing Disease means any condition, ailment, injury or disease:

a) That is/are diagnosed by a physician within 48 months prior to the effective date of the policy issued by the insurer or

a) That is/are diagnosed by a physician within 48 months prior to the effective date of the policy issued by the insurer or

b) For which medical advice or treatment was recommended by, or received from, a physician within 48 months prior to the effective date of the policy or its reinstatement

b) For which medical advice or treatment was recommended by, or received from, a physician within 48 months prior to the effective date of the policy or its reinstatement

c) A condition for which any symptoms and or signs if presented and have resulted within three months of the issuance of the Policy in a diagnostic illness or
medical condition.

Deleted

(Life insurers may define
norms for applicability of
PED at Reinstatement)

(Life insurers may define
norms for applicability of
PED at Reinstatement)

Source: IRDAI

IRDAI has advised all the insurance providers and third-party administrators to make amendments and ensure compliance, wherever applicable, with immediate effect

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