Pre-existing Diseases in Health Insurance Plans: How You Can Cover Them in Your Policy

While there has been an increased awareness and penetration of health insurance in India in recent years, many people purchase policies without fully understanding the intricacies of the features and terms & conditions. Policyholders often neglect the task of reading and understanding policy documents because they contain complex terminologies that are difficult for an average person to grasp. However, this lack of knowledge can result in the rejection of health insurance claims for various reasons, such as claims for pre-existing conditions, failure to complete the waiting period or survival period, claims for illnesses not covered by the policy, and so on.

To ensure that your health insurance claims are successfully settled, you should carefully read and understand all the terms and conditions of the policy before making a purchase. This article elucidates what pre-existing diseases are, which is one of the important terminologies used in health insurance that you should be aware of before buying a health insurance policy, and how you can cover them under your policy.

What are pre-existing diseases?

Pre-existing diseases refer to the medical conditions that an individual already has at the time of purchasing a new health insurance policy.

The Insurance Regulatory and Development Authority of India (IRDAI) defines pre-existing diseases as follows:

a) Any condition, ailment, injury, or disease that has been diagnosed by a physician within 48 months before the policy's effective date or reinstatement.

b) Any medical advice or treatment recommended by, or received from, a physician within 48 months before the policy's effective date or reinstatement.

What are the examples of pre-existing diseases?

Here are some common examples of pre-existing diseases:

• Hypertension

• Diabetes

• Heart diseases

• Arthritis

• Asthma

• Thyroid

• Kidney diseases

• Cancer

• Mental illnesses, such as depression, anxiety, bipolar disorder, etc.

How does it impact your health insurance policy?

Do not let a pre-existing disease discourage you and your family from safeguarding your financial well-being. When you truthfully disclose your pre-existing condition during the insurance application process, here's how this condition can impact your policy and premiums:

Waiting Period:

When completing a health insurance application form, it is necessary to disclose any pre-existing diseases or illnesses that you may have. Generally, health insurance companies provide coverage for these conditions after a waiting period of 2 to 4 years from the commencement of the policy. However, if a policyholder fails to disclose their pre-existing health conditions and the insurance company discovers this during a claim process, the claim will be rejected, and the policy may even be terminated. Therefore, to avoid such situations, it is advisable to thoroughly review the policy document and provide accurate information without hiding or misrepresenting any details.

Premium:

In some cases, it is possible to obtain immediate coverage for a pre-existing disease; however, this typically comes at a higher premium. The additional amount is included in the premium to account for the risks associated with insuring an individual who already has a medical condition. It is quite common for ailments like diabetes and heart disease to result in premium loading. Despite the higher premium, you can rest assured that you are protected, as the insurance will cover all expenses in the event of extended hospitalisation or worsening of the condition. It is worth noting that an insurance company can only adjust your premium based on your pre-existing disease at the time of policy purchase. As mandated by the IRDAI, no insurance company can increase your premium for any disease that occurs after issuing and renewing the policy without any breaks.

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Depending on the criticality of the case, the insurance company has the option to increase the premium amount as well as enforce a waiting period.

Why do pre-existing diseases impact your health insurance?

The likelihood of individuals with pre-existing conditions filing insurance claims is higher when compared to those without such conditions. This poses an increased financial risk for health insurance providers, leading them to refrain from offering medical insurance to individuals with pre-existing diseases. Predicting illnesses in advance is challenging, but those already dealing with health issues are more likely to fall ill and make claims. Consequently, health insurance companies mitigate their financial burden by excluding coverage for individuals with pre-existing ailments.

How to cover pre-existing diseases in your health insurance plan?

To cover pre-existing diseases in your health insurance plan, you should be aware of certain things:

1. The list of pre-existing diseases may differ from insurer to insurer:

Health insurance policies vary in terms and conditions, particularly related to pre-existing conditions. Hence, make sure you thoroughly review the waiting periods and the list of pre-existing diseases covered by your health insurance policy.

2. You can get coverage for the pre-existing disease after 48 months:

Health insurance coverage can be challenging if you have a pre-existing medical condition. Nevertheless, according to the most recent guidelines established by IRDAI, health insurance companies are allowed to assess the medical history of only the past 48 months to determine pre-existing diseases. So, 48 months after your pre-existing disease was diagnosed or treated, you can purchase a health insurance policy with pre-existing disease coverage.

3. Not every disease or illness is counted as a pre-existing disease:

Regarding pre-existing conditions, health insurance companies solely focus on health ailments that have long-term implications. As a result, there is no need to worry if you are susceptible to temporary illnesses like flu, cough, cold, or fever. Such short-term health issues are not considered pre-existing ailments since they do not have lasting side effects.

4. Do not hide or conceal any information:

You should never hide or conceal any pre-existing health information from your insurance provider when purchasing or renewing a policy because if the insurer comes to know about your pre-existing condition during treatment or claim settlement, the insurer has the right to reject your health insurance claim.

5. Check the Pre-existing diseases waiting period:

Whether you opt for an individual or a family health insurance plan, a waiting period for pre-existing diseases prevents you from filing a claim for a specified duration. Within this period, your insurance company will deny any claims related to such diseases.

Moreover, the length of this waiting period can vary depending on the specific insurance policy and the duration and severity of your pre-existing condition. Hence, choosing a health insurance policy that offers a shorter waiting period for pre-existing diseases is advisable.

6. Check the co-payment clause:

Certain health insurance providers may include a co-payment clause for coverage of pre-existing conditions. In such cases, during claim settlement, you will be responsible for paying a percentage of the claim amount or a fixed amount, while the insurer will cover the remaining cost. However, note that not all health insurance policies have this co-payment clause for pre-existing disease coverage. Hence, it makes sense to buy a health insurance plan that does not have a co-payment clause.

7. You might have to undergo a medical exam:

If you have a pre-existing condition, the insurance company can request a medical examination before accepting your application, and the premium for your policy will be determined based on the examination result. For instance, if the insurer considers you a high-risk individual based on the result, they might charge you a higher premium than what was initially quoted. In certain cases, if the results are unfavourable, there is a possibility that the insurance company may decline to offer you a policy.

8. Your proposal can get rejected:

The terms and conditions of health insurance policies differ, especially when it comes to pre-existing conditions. Based on the severity of your pre-existing disease, the health insurance company can reject your application. Hence, it is crucial to carefully examine the waiting periods and the specific list of pre-existing diseases covered by your health insurance policy.

To conclude:

Navigating the realm of health insurance and pre-existing conditions can be complex, but understanding key aspects can help you make informed decisions. From waiting periods to coverage clauses, it is crucial to carefully review the terms and conditions of different health insurance policies. Ensure you disclose any pre-existing conditions honestly to avoid claim rejections. Consider policies with shorter waiting periods, comprehensive coverage for pre-existing diseases, and without co-payment clauses. By doing so, you can secure a health insurance policy that offers the necessary coverage and peace of mind, providing financial support during times of medical need.

KETKI JADHAV is a Content Writer at PersonalFN since August 2021. She is an MBA (Finance) and has over seven years of experience in Retail Banking. Ketki specialises in covering articles around banking, insurance, personal finance, and mutual funds and has been doing it for over three years now.

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Disclaimer: This article is for information purposes only and is not meant to influence your investment decisions. It should not be treated as a mutual fund recommendation or advice to make an investment decision.