Pre-existing Diseases in Health Insurance

What is a Pre-existing Disease?

A pre-existing disease or PED is an illness or medical condition that the policyholder has before purchasing a health insurance policy. As per the Insurance Regulatory and Development Authority of India (IRDAI), if the insured was diagnosed with a disease or medical condition up to 48 months before buying the policy, it is termed as a pre-existing illness.

Some of the common examples of PED include all the long-term health issues such as high blood pressure, diabetes, thyroid, asthma, etc.

Pre-existing Diseases Waiting Period

Almost all health insurance companies in India cover pre-existing diseases after a waiting period. During this period, any claim raised for the treatment of a PED will be rejected by the insurer. Generally, most mediclaim plans cover PED after a waiting period of 2-3 years, which might vary between insurers.

Moreover, there are some mediclaim insurance plans that offer a reduction in PED waiting period rider. With this rider, you can reduce your pre-existing disease waiting period by paying an extra premium amount. In fact, multiple healthcare policies now offer PED coverage from Day 1.

NOTE: Previously, the maximum PED waiting period was capped at 4 years, but after the recent IRDAI guidelines, it has been reduced to 3 years.

Why Do Health Insurance Companies Dislike Pre-existing Diseases?

Insurance companies are apprehensive about providing health insurance coverage to people suffering from PEDs.

Wondering why?

It is because people with pre-existing ailments are more likely to file health insurance claims as compared to other people. This imposes higher financial risk on the health insurance providers and therefore, they dislike offering medical insurance to people with pre-existing diseases.

Why Disclose Pre-existing Diseases to Your Insurer?

When purchasing health insurance, it is essential to be honest about any pre-existing diseases you may have. While many people think that hiding PED can help secure a lower health insurance premium or easier approval, but it can lead to serious consequences.

If an insurer discovers that you have not disclosed your pre-existing illnesses, they have the right to reject your claim, especially if the treatment is related to that undisclosed illness. This could leave you facing high medical bills without financial support. Non-disclosure of PED can also result in policy cancellation, leaving you uninsured.

Tips to Buy Health Insurance If You Have a Pre-existing Disease

Check out some useful tips that can help you find a suitable health insurance policy even if you have a pre-existing health issue:

1. PED Coverage Can be Availed After 48 Months

   It can be challenging to get health insurance coverage when you have a pre-existing health condition. However, as per the latest IRDAI guidelines, health insurance companies can consider the medical history of only the last 48 months to find a pre-existing disease. Therefore, you can buy health insurance with pre-existing disease coverage 48 months after your pre-existing disease was diagnosed/cured.

2. Do Not Hide any PED

   Refrain from hiding any pre-existing health issue from your insurance company at the time of buying the policy. This is essential because if your pre-existing condition is disclosed at the time of treatment, then the insurer can reject your health insurance claim.

3. Every Visit to the Doctor Does Not Count as a PED

   When it comes to pre-existing diseases, health insurance companies will only take into consideration your health ailments that will have an impact in the long run. Therefore, if you are prone to flu, cough, cold or fever, then do not fret! The insurance company will not consider such short-term health issues as pre-existing ailments as they do not have long-term side effects.

4. Opt for a Health Plan with a Lower PED Waiting Period

   Whether you buy an individual health plan or a family health insurance plan, you should opt for a health insurance policy that comes with a lower PED waiting period.

5. Avoid Health Plans with Co-payment Clause for PED Coverage

   Some health insurance providers may have a co-payment clause for pre-existing conditions coverage. Under this clause, you will have to pay a percentage of the claim amount during claim settlement, and the insurer will pay the outstanding amount. However, not every health policy comes with this co-payment clause for covering pre-existing diseases. Hence, buy a health plan that does not come with a co-payment clause.

Things to Know About Pre-Existing Conditions in Health Insurance

Here are a few things that you must know about PED coverage in mediclaim insurance:

• Always inform the insurer about your pre-existing conditions to avoid claim rejection or policy cancellation later.
• Most insurers cover pre-existing diseases after a waiting period, usually ranging from 2 to 3 years, depending on the policy.
• You can opt for a PED reduction rider, if available, to reduce the pre-existing disease waiting period under your mediclaim policy.
• Some insurers offer plans that cover PED from Day 1.Since pre-existing conditions increase risk, insurers may charge a higher premium or offer limited coverage.
• Some insurers ask for a health check-up before issuing a policy, especially if you have a history of medical conditions.