Pre-Existing Diseases In Health Insurance

With the average medical expense of a person living in India going up every passing year, it can be said that the average health of a person is deteriorating. This means we are more prone to infections than our parents and our parents are more prone to diseases than the generation before. To mitigate the financial risk that comes with such issues, we take up health insurance. Often a health insurance policy comes up with various clauses that are beyond our understanding. One such clause can be related to pre existing diseases.

Pre existing Disease Meaning

IRDAI defines pre existing disease as any condition, ailment, injury or disease which is diagnosed by a physician within 48 months prior to the effective date of the policy issued by the insurer or its reinstatement or 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 issued by the insurer or its reinstatement. In simple words, the pre existing disease meaning is any disease that you are diagnosed with within 2 years prior to taking up a policy. It has the potential of becoming a severe disease in long term.

What is included and excluded from the criteria of pre existing diseases in health insurance?

Pre existing diseases in health insurance generally include now common diseases like blood pressure, diabetes, thyroid, and cholesterol. It is important to understand that common diseases like fever, viral flu, cough and cold, etc., which don’t have any potential to get severe in the long run, are not included in pre existing diseases.

Are pre existing diseases totally excluded from health insurance policy coverage?

A common question that people have after knowing what pre existing disease in health insurance is whether all the claims related to the pre existing disease are excluded from health insurance coverage. The answer to that is ‘NO’. Claims related to such diseases are honored by health insurance companies after the completion of the waiting period. The waiting period is the time when the claims related to existing diseases cannot be made by the insured. This period generally varies from 2 to, four years and it depends from provider to provider. It is advisable to take the policy with a lesser waiting period if you expect to make a claim in relation to this disease in near future.

Points to be considered in pre existing diseases

Identification of pre existing disease

First, an understanding of pre existing disease’s meaning has to be given to the probable policyholder, which makes it easier for him to assess and decide whether he has any such conditions or not. It is recommended to opt for a higher sum insured while buying health insurance to tackle pre existing conditions.

Disclosure of full medical history

The insurance company may also ask you about other health conditions you are in; others prefer only the last 2 to 5 years of medical history disclosures. This depends on provider and policy terms and conditions. It is in the interest of the policyholder that he discloses all the details fully and truly.

Pre insurance health check-up

Identification of pre existing diseases may require you to go through a medical check-up that can determine the condition of your health.

Choosing a policy with reference to the waiting period

If you are expecting the situation to get worse in near future, it is advisable to choose a policy with a shorter waiting period. This is a personal assessment based on the medical conditions of an individual.

What happens if I don’t disclose pre existing diseases?

Non-disclosure of the pre existing disease can result in denial at the time of renewal of the policy or dishonoring of claims if made for such diseases.

Is there any effect of pre existing diseases on the amount of premium?

Yes, generally, the amount of insurance premium is higher in case of pre existing illnesses as the chances of making a claim is higher in such cases.

Frequently Asked Questions

Is there any way of reducing the waiting period for pre existing illnesses? Yes, the waiting period can be reduced to one year after paying some amount in addition to the premium payment. Does pre existing disease affect the amount of coverage? No, coverage of any insurance is a personal decision and has no relation to pre existing diseases. Ramesh asks, “I suffered a heart attack and in need of a bypass. This is something I discovered six months after taking the policy. Is it called pre existing illness?” No, as the condition came to the knowledge after taking the policy, it cannot be called pre existing illness. Dhyana asks, “what are the consequences if I am aware of some condition qualifying pre existing illness, but I won’t disclose it to the insurance company, and later due to this condition, I am hospitalized, and I put forward a claim in this regard?” The insurance company can decline the claim on the basis of non-disclosure of a pre existing condition.