Pre-existing Disease in Health Insurance

Pre-existing Disease in Health Insurance

A pre-existing disease, in the context of health insurance, refers to any condition, ailment, injury, or disease that an individual has been diagnosed with by a physician within 48 months prior to the effective date of the insurance policy issued by the insurer. It also includes conditions for which medical advice or treatment was recommended or received within the same 48-month period.  

Pre-existing illnesses can range from common conditions like diabetes, hypertension, asthma, and thyroid disorders to more serious illnesses like heart diseases, cancer, kidney diseases, and mental health conditions. The number of people suffering from these conditions seems to be growing, making a strong case for health insurance for pre-existing disease.  

For example, according to the International Diabetes Federation, India has one of the highest numbers of people living with diabetes globally. As of the IDF’s latest estimates, around 77 million adults aged 20-79 years in India had diabetes in 2019, and this number is expected to rise to over 100 million by 2030.

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What Is a Pre-existing Disease?

As per the Insurance Regulatory and Development Authority of India (IRDAI), a pre-existing disease is any condition, ailment, or injury for which signs or symptoms were present, diagnosed, or received medical advice or treatment within 48 months prior to the first policy issued by the insurer and continuously renewed thereafter.  

Common pre-existing illness covered by health insurance in India include high blood pressure, diabetes, asthma, thyroid disorders, heart conditions, cancer, and more. These conditions are considered serious and may impact the coverage and waiting period of health insurance policies.  

Health insurance companies in India may offer coverage for prior existing diseases after the waiting period is over. Some insurers provide options to reduce the waiting period for pre-existing conditions by paying an additional premium.

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Why Is Pre-existing Disease Health Insurance Important?

Pre-existing disease health insurance is crucial for individuals with pre-existing conditions due to several key reasons highlighted in the provided sources: 

1. Financial Protection

A health insurance plan for prior existing illness provides financial protection against high healthcare costs associated with managing these conditions. It covers expenses like hospitalisation, consultations, surgeries, and diagnostic tests, ensuring that individuals can access necessary medical care without facing significant financial burdens.

2. Timely and Uninterrupted Care

Having a health insurance plan that covers pre-existing diseases ensures timely and uninterrupted care, which is essential for managing existing conditions effectively and preventing complications.

3. Access to Quality Healthcare 

Pre-existing disease health insurance grants individuals access to high-quality medical treatment from reputable healthcare providers. This ensures that individuals receive the best possible care for their conditions, enhancing their overall health outcomes and quality of life.

4. Disclosure and Transparency

5. Reduced Waiting Periods 

Some health insurance providers offer options to reduce the waiting period for prior existing conditions by paying higher premiums. This feature allows individuals to access coverage for their pre-existing diseases sooner, providing them with timely financial support for their healthcare needs. 

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List of Pre-existing Diseases Covered in Health Insurance

Here is a list of  pre–existing diseases covered by health insurance companies in India. 

Types of Health Insurance Plans Covering Pre-existing Conditions

In India, health insurance plans covering prior existing conditions are available through various insurers. Here are some types of health insurance plans that typically cover pre-existing conditions:

1. Individual Health Insurance

These are policies purchased by individuals directly from insurance companies. Many individual health insurance plans in India cover existing conditions, although there may be waiting periods and specific terms and conditions. 

2. Family Floater Health Insurance

3. Group Health Insurance 

Group health insurance plans are provided by employers to their employees or by organisations to their members. Many group health insurance plans cover pre-existing conditions, although coverage and terms may vary. 

4. Senior Citizen Health Insurance

These plans are designed specifically for elderly individuals. Many senior citizen health insurance plans in India cover existing conditions, although premiums may be higher, and there may be waiting periods. 

5. Government Health Insurance Schemes

In India, there are various government health insurance schemes such as Ayushman Bharat, Rashtriya Swasthya Bima Yojana (RSBY), and state-specific schemes. These schemes often cover prior existing conditions for eligible beneficiaries. 

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Waiting Period for Pre-existing Diseases in Health Insurance 

The waiting period for pre-existing diseases in health insurance typically ranges from 2 to 4 years, depending on the insurance provider and the specific health plan. During this period, any claims related to existing diseases will not be covered by the insurance provider. There are several types of waiting periods in health insurance, including:

1. Initial waiting period: A general waiting period that applies to all policyholders, usually ranging from 30 days to 90 days. 

2. Pre-existing diseases (PED) waiting period: A special waiting period for prior existing diseases disclosed at the time of policy purchase, typically ranging from 1 to 4 years. 

3. Waiting period for specific diseases: A waiting period for specific diseases or ailments, such as hernia, tumour, ENT disorder, cancer, stroke, cardiac ailments, usually ranging from 2 to 4 years. 

4. Maternity waiting period: A waiting period for maternity and newborn baby cover, usually ranging from 2 to 4 years. 

5. Waiting period for bariatric surgery: The waiting period for bariatric surgery in health insurance policies can vary depending on the insurer and the specific health plan. 

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What Is Pre-existing Disease Covered from Day 1?

“Pre-existing disease covered from day 1” typically refers to a feature in certain health insurance policies where coverage for pre-existing conditions begins immediately upon the policy’s effective date, without any waiting period. This means that individuals with prior or existing conditions can avail themselves of benefits related to those conditions from the very start of the policy, without having to wait for a specific period. 

However, it’s essential to note that not all health insurance policies offer coverage for pre-existing conditions from day 1. Many policies impose waiting periods during which coverage for pre-existing conditions is not available, or they may offer coverage for pre-existing conditions only after a certain waiting period has elapsed. 

When purchasing health insurance, individuals with prior existing conditions should carefully review the policy documents, including any waiting periods or exclusions related to these conditions. Some insurers may offer plans with coverage for pre-existing conditions from day 1 as a specific feature or as part of a comprehensive package.

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How Do Pre-existing Diseases Impact Health Insurance Policies?

Pre-existing diseases can have several impacts on health insurance policies. Some are as follows: 

1. Waiting Periods 

Many health insurance policies have waiting periods for coverage of these conditions. During this time, typically ranging from 1 to 4 years, the policyholder may not be eligible for coverage related to such conditions.  

2. Premiums

3. Exclusions

4. Limited Coverage

5. Specialised Plans

6. Portability

7. Government Regulations

In some countries, government regulations may impact how insurers handle pre-existing conditions. 

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Do’s and Don’ts in Case of Pre-existing Disease

Here are the do’s and don’ts in the case of pre-existing disease when dealing with health insurance policies: 

Do’s: 

1. Disclose all information

It is crucial to inform the insurance provider about any prior existing medical conditions honestly and accurately when applying for a health insurance policy.

2. Undergo medical check-ups

Before purchasing a health insurance plan for pre-existing illness, consider undergoing a comprehensive health check-up to understand your overall health condition and screen for pre-existing diseases.

3. Read the policy brochure

Review the policy brochure carefully to understand which medical conditions are considered pre-existing diseases and ensure you are aware of the coverage details.

4. Be transparent

Always be honest and transparent with the insurance company regarding your medical history and pre-existing conditions to avoid complications during the claim settlement process.

5. Follow waiting period guidelines

Understand the waiting period specified in your policy for a pre-existing condition and adhere to the waiting period requirements before making claims related to pre-existing conditions.

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Don’ts: 

1. Hide pre-existing diseases

Avoid concealing any information about your medical history or pre-existing conditions from the insurance provider. Failure to disclose prior existing health conditions can lead to claim rejections and policy cancellations.

2. Misrepresentation

Providing false information or hiding prior existing diseases can breach the trust between you and the insurance company, leading to claim rejections and policy cancellations.

3. Delay renewal

Ensure timely renewal of your health insurance policy to maintain continuity benefits and avoid losing renewal benefits and accrued additional sum insured earned through continuous renewal.

4. Expect immediate coverage

Understand that pre-existing diseases may not be covered immediately and that there is a waiting period specified in the policy before coverage begins for these conditions.

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Things to Consider While Buying Health Insurance for Pre-existing Diseases

When buying health insurance for a pre–existing illness, there are several important factors to consider to ensure adequate coverage and smooth claim processes. Here are the key things to keep in mind: 

1. Undergo Pre-policy Medical Check-ups

Some insurers may require applicants with pre-existing conditions to undergo pre-policy medical check-ups to assess their health status. These check-ups can impact the premium amount and coverage offered by the insurer.

2. Premium Loading

3. Policy Inclusions and Exclusions  

4. Comparison of Plans

Compare different health insurance plans to find one that offers comprehensive coverage for pre-existing diseases at a competitive premium. Consider factors like waiting periods, coverage limits, network hospitals, and additional benefits before making a decision. 

Also, Read: Health Insurance Claim Process

Tips to Buy a Health Insurance Policy for Pre-existing Diseases

When buying a health insurance policy for a pre-existing illness in mind, here are some tips to consider:

• Research extensively: Look for insurers who specialize in covering pre-existing conditions or offer policies tailored to individuals with chronic health issues.

• Compare policies: Compare the features, benefits, premiums, waiting periods, and coverage limits of various health insurance policies. 

• Understand waiting periods: Be aware of waiting periods imposed by insurers for coverage of pre-existing conditions. Choose a policy with a waiting period that aligns with your healthcare needs and budget.

• Check coverage terms: Review the coverage terms and conditions of the policy thoroughly, including any limitations, sub-limits, and exclusions related to pre-existing conditions. 

• Declare pre-existing conditions: Provide accurate and complete information about your pre-existing conditions when applying for health insurance. Failure to disclose pre-existing conditions during the application process may lead to claim denials or policy cancellations later on.

• Consider premiums vs. Coverage: Balance the cost of premiums with the level of coverage provided. 

• Read reviews and seek recommendations: Read customer reviews and seek recommendations from friends, family, or healthcare professionals who have experience with health insurance policies covering pre-existing conditions. 

• Check network hospitals: Ensure that the insurer has a wide network of hospitals and healthcare providers in your area.
• Review renewal terms: Understand the renewal terms of the policy, including any changes to premiums, coverage, or terms related to pre-existing conditions.

Also, Read: Does Group Health Insurance Cover Pre-existing Disease?

Conclusion 

Health insurance for pre-existing disease is a critical aspect of financial planning and healthcare management for individuals with chronic conditions. Pre-existing disease, ranging from common ailments like diabetes, hypertension, asthma, and thyroid disorders to more serious illnesses like heart diseases and cancer, can have a significant impact on an individual’s health and quality of life.  

Health insurance coverage for pre-existing diseases offers financial protection against high healthcare costs, ensures timely and uninterrupted care, grants access to quality healthcare, promotes transparency through disclosure, and may reduce waiting periods for coverage. 

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