Pre-Existing Diseases in Health Insurance: Explained

Often insurance buyers are troubled with the question ‘Will I get health insurance cover if I’m already diagnosed with an ailment?’. While the short answer is yes, underlies the concept of pre-existing diseases.

Along with other terminologies, it is critical to understand how pre-existing diseases affect medical insurance coverage. Here in this article, you can learn more about it.

What are pre-existing diseases?

Pre-existing diseases or PEDs are the ailments that the policyholder is diagnosed with before the purchase of the insurance policy. Every insurer has a clause for pre-existing diseases in the terms of its policy. This clause defines how a specified pre-existing disease is covered under the insurance policy. It is crucial to thoroughly be aware of this clause as it is often the case for acceptance or rejection of insurance claims.

The recent amendment in regulation has deleted the condition where the insurance company could reject the claim if it was reported within 3 months of enrolment to be considered as PED. At present, the maximum waiting time for a pre-existing ailment is 48 months if the insurance policy is renewed without any discontinuity.

Which ailments are the ones that are commonly included in the list of PEDs?

While there are no specified set of ailments that are considered as pre-existing diseases. However, arthritis, asthma, diabetes, any stage of cancer, glaucoma, hypertension, Crohn’s disease, gastrointestinal issue, cardiac ailments are some that are commonly considered PEDs

Waiting period for PEDs

Insurance, be it standard or critical illness insurance covers the specified illness after the waiting period. These waiting periods differ among insurance companies and their plans between one year to four years of continuous coverage depending on the terms and conditions. Once this duration is complete, the insurance policy’s coverage includes the ailments classified as PED. For cases where the sum insured is enhanced by the policyholder, the waiting period and the exclusions will apply afresh only to the incremental component of the sum assured.

Disclosure of pre-existing diseases

The underlying principle based on which health insurance policies are is utmost good faith. So, any information hidden from the insurer at the time of application can lead to a sufficient cause of rejection at the time of claim. To avoid such rejections, it is advisable to disclose all the pre-existing conditions when purchasing the insurance cover.

What are the things to note about pre-existing diseases?

  • The list of PEDs is not the same for every insurance company. Thus, it is advisable to read the policy terms thoroughly at the time of purchase.
  • As there is a clause of pre-existing diseases, there are policies that offer waivers too. Enquiring with the insurance company will help to know more about it.
  • The duration of time for PEDs differs from the waiting period otherwise mentioned in the policy document. The waiting period is applicable for all policyholders whereas the wait time under PED is case-specific.
  • The portability feature of insurance plans in India does not require to re-serve the waiting period on migration to a different insurance company.
  • Any changes in the sum insured reset the pre-existing clause. It is essential to remember this for cases where a plan is purchased for a lower sum assured whereas increased at a later date.

While purchasing a health cover, make use of a health insurance premium calculator that not only helps select the right add-ons, but also make a suitable choice of an insurance policy. Do not forget to go through the policy terms that will enable a prudent decision making of your policy purchase.