Pre-existing Diseases (PEDs) in Health Insurance Cover

Pre-existing Diseases (PEDs) in Health Insurance Cover

A Health Insurance cover’s relevance in India is unquestionable. Our evolving lifestyles, unreasonable work schedules/eating habits, dangerously rising pollution levels, increasing healthcare costs make all of us prone to multiple health disorders and reiterate the necessity of a health insurance policy.

Your insurance addresses doctor’s/ambulance’s fees, hospitalization/posthospitalization charges, medicine bills, annual health checkups, preventive services and other expenses. It also brings the much-needed peace of mind.

Fortunately, there is growing awareness around health insurance; however, many Indians still end up ignoring a critical aspect while taking out a health cover – Pre-existing Diseases (PED) or Pre-existing Conditions.

It is a condition, ailment or injury or related condition(s) for which the
policyholder had signs or symptoms, and/or was diagnosed, and/or for which
medical advice/treatment was received within 48 months prior to the first policy issued by the insurer and renewed continuously thereafter. Also includes a condition for which any symptoms and/or signs if presented and have resulted within three months of the issuance of the policy in a diagnostic illness or medical condition will be treated as PED.
”– IRDAI (Insurance Regulatory and Development Authority of India).

After spending a decent amount on health insurance, would you prefer being sufficiently covered with zero surprising claim rejections and a hasslefree settlement process?

If your answer is “Yes”, please spend a minute or two in briefly understanding what Pre-existing Diseases/Conditions, Waiting Periods are and how they impact you.

Pre-existing Diseases

  • Diseases, injuries, ailments, illnesses and conditions an individual is suffering from at the time of buying a health insurance policy.
  • The PEDs are usually excluded from the insurance coverage for an initial waiting period that could last up to 4 years.
  • Examples: Serious medical conditions (cancer, diabetes), ailments (thyroid, allergies, high blood pressure), symptoms/signs policyholder has acquired or is now suffering from and prior surgeries or hospitalization.
  • Includes a history of heart attack, signs of obesity or an increase in sugar level, symptoms such as experiencing brain fog, sweating profusely, skin disorders and medication for hypertension.
  • Insurers only consider ailments or medical conditions which have had a long-lasting effect on an individual’s health. Many minor ailments or side-effects are not taken into account.
  • As per IRDAI’s recently modified definition, with effect from 1st October 2019, pre-existing diseases will also include those diagnosed within three months of purchasing a health insurance policy.

Waiting Period

  • A specific cooling period before a particular list of diseases/ailments starts getting covered.
  • 4 years waiting period is considered a standard clause for most health insurance policies. It could also be 2-3 years, depending on the plan.
  • In case policyholders incur expenses related to ailments mentioned in the list; they will have to pay on their own.
  • Any disease diagnosed for the first time during a waiting period will not be called a pre-existing disease.
  • Some insurers may offer an option to reduce the waiting period by paying an extra amount.
  • The insurer cannot deny a claim once the waiting period is over.
  • Other diseases or illnesses that are not pre-existing continue to get covered.

In addition to the pre-existing diseases waiting period, other common ones are:

  • General or initial health insurance waiting period: 30-90 days. Accidental cases are exempted. During this period, no diseases or ailments, preexisting or not, are covered.
  • Waiting period for infants/new-born babies: 90 days.
  • Maternity benefits waiting period offered by some companies: 9 months-3 years.
  • Listed ailments-related waiting period: 1-2 years. Not the same as pre-existing diseases waiting period that covers conditions you already have. This one applies to ailments like hernia, ENT disorders, diabetes and osteoporosis.

Why Declare PEDs?

  • Declaring them at the time of buying your health insurance allows insurance providers’ health underwriters to assess the impact of diseases on the policyholder.
  • It lets them decide if the insurance proposal must be accepted or not, and if accepted, they can prescribe a waiting period. All hospitalization expenses on declared diseases/ailments can then be claimed only after this period. Informing the insurance company prevents potential claim rejections.
  • Some companies are willing to go ahead with the insurance cover by placing terms and conditions. Therefore, mentioning pre-existing diseases at the time of policy purchase will keep you updated on these conditions.
  • In most likelihood, the insurance company would discover your preexisting diseases the moment a claim is made. In such a situation, they can entirely deny the claim and terminate the contract without refunding any premium.

Transparency is the best approach at the time of finalizing a health insurance policy for yourself and your loved ones. Hiding information about pre-existing diseases or conditions can stop you from extracting maximum benefits out of your chosen cover.

There are insurance companies in India that provide benefits cover called ‘preexisting condition waiver’ that can waive off exclusions and cover hospitalization expenses.

Carefully study all details, disclose pre-existing diseases, know how long the waiting period is, and try to adopt an insurance plan with the shortest waiting period.

At Quickinsure, you can explore a variety of healthcare covers by comparing quotes from recognized health insurance providers.

Sources: IRDAI, The Economic Times & Multiple other sources.

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