Does Health Insurance Cover Congenital Diseases in India?

What are Congenital Diseases?

Congenital diseases refer to the diseases that are present in people right from birth. They are structural or functional birth defects that develop during the intrauterine life of a baby. Also known as congenital anomalies or genetic disorders, they can be detected before birth, at birth or during infant years.

Genetic mutations, environmental factors, maternal age, maternal nutritional status, infections and socioeconomic factors are some of the common causes of congenital anomalies in infants.

As per a joint report by WHO and MOD in 2016, around 1.7 million people in India suffers from congenital diseases, which is 6-7% of the total population. While internal congenital diseases are not clearly visible, external congenital anomalies can be easily identified. Nevertheless, a baby suffering from a congenital disorder may have health problems or suffer from disability throughout his/her life.

Common Types of Congenital Diseases

Some of the most common types of congenital diseases are as follows:

Down syndrome
Congenital heart disease
Cleft lip and cleft palate
Cerebral palsy
Spina bifida
Club foot
Edward’s syndrome
Thalassaemia
Phenylketonuria
Fragile X syndrome
Cystic fibrosis
Sickle cell disorder
Congenital hypothyroidism

Treatment of Congenital Diseases

The treatment of a congenital disease depends on its type and diagnosis. Most functional congenital diseases in children can be treated at early stages through medication to manage symptoms and prevent complications.

However, children suffering from a structural congenital anomaly may require paediatric surgery to correct the problem. Needless to say, both long-term medications and paediatric surgery will be an expensive affair.

Moreover, doctors may require a pregnant mother to undergo various tests to detect a congenital disorder.

Although some congenital diseases, such as down syndrome, can be detected prenatally through a blood test, others may require chronic villus sampling (CVS), ultrasound scans, amniocentesis, etc. to identify the disorder. The cost of these tests can also eat away your savings.

Are Congenital Diseases Covered by Health Insurance Plans in India?

Yes. All regular health insurance plans in India provide coverage for congenital diseases as per the 2019 guideline of IRDAI (Insurance Regulatory & Development Authority of India).

They cover the medical expenses incurred on the diagnosis and treatment of congenital diseases, including the cost of in-patient hospitalization, day care procedures, surgeries, pre-hospitalization, post-hospitalization, etc. The coverage amount can range from Rs 50,000 to up to Rs 6 crore. Though, the scope of coverage and the coverage amount depends on the health insurance plan that you have purchased.

However, not all congenital diseases are covered by health insurance plans in India. As per the IRDAI guidelines, only internal congenital diseases are covered by regular health insurance plans. If a person is suffering from an external congenital disease, the insurance company will not be liable to provide coverage for the treatment cost.

Waiting Period to Cover Congenital Diseases by Health Insurance Plans

Although health insurance plans cover internal congenital diseases in India, you cannot avail coverage unless the waiting period is over. Most health insurance policies cover congenital diseases after a waiting period of 2 years.

This means that you cannot raise a claim for congenital diseases under your health policy until two consecutive renewals. Once the waiting period is over, you can easily get the treatment expenses for internal congenital diseases covered by your insurance company.

However, the 2-year waiting period for congenital anomalies is applicable only if your child is diagnosed with the disease after buying the health policy. In case your child was diagnosed with an internal congenital disorder before you purchased the policy, it will be considered as a pre-existing disease.

In that case, you will have to wait out for up to four renewals to be able to raise a claim for congenital diseases under your policy. This is because all pre-existing diseases are covered by health insurance providers after a waiting period of 2-4 years.

Therefore, make sure to check your policy documents carefully to know the exact waiting period for congenital diseases and pre-existing diseases.

Tips to Prevent Congenital Diseases

As a woman, you can take the following precautions to prevent the onset of congenital diseases in your child. Take a look:

Eat nutritious food rich in vitamins, minerals
Maintain a healthy body weight
Take folic acid supplements during reproductive years and in the first trimester of pregnancy
Avoid consumption of alcohol, drugs and cigarettes during pregnancy
Avoid consuming medicines that can lead to birth defects
Avoid exposure to hazardous chemicals like pesticides and lead
Get appropriately vaccinated, especially against rubella
Avoid travelling to places with the outbreak of an infection like the Zika virus
Keep your diabetes under control (if applicable)

Summing It Up

Congenital diseases have lifelong ramifications. Not only will your child have to deal with various health problems throughout his/her life, but the treatment expenses will also evaporate your savings in no time. The good news is that health insurance plans in India provide coverage for internal congenital diseases. Nonetheless, it is better to follow the above-mentioned tips and do your best to prevent your child from developing a congenital disorder.