Does Group Health Insurance Cover Pre Existing Disease?

  • postauthorOnsurity Editorial
  • postdateJuly 26, 2023
  • postreadtime4 min read
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Offering group health insurance coverage to employees is a clear indication of your commitment to their well-being. However, selecting the right group health insurance plan is crucial to ensure comprehensive coverage for your employees. Human resources professionals today are seeking more inclusive plans that encompass maternity coverage, outpatient department (OPD) benefits, wellness programs, and coverage for pre existing disease.

When choosing a group health insurance plan, it is important to determine whether pre-existing diseases are covered or not. Read on to learn about all about coverage offered health insurance for pre existing medical conditions.

Are pre-existing diseases covered in employer-provided group health policies? 

Yes, some insurers offer coverage for pre-existing diseases under group health insurance plans, but usually after a waiting period of 36-48 months. However, a few insurers provide coverage for PED from day one of the policy. 

 What is a pre-existing disease? 

A pre-existing disease refers to a medical condition that a policyholder has been diagnosed with before purchasing the insurance policy. Any disease diagnosed in the 48 months prior to policy purchase is considered a pre-existing disease. Examples include diabetes, thyroid disorders, hypertension, asthma, and cancer. It is important to note that coverage for pre existing disease and associated conditions is typically provided after the completion of the waiting period. 

Under group health insurance, a master policy is issued in the name of the employer, and employees receive individual policy copies featuring their names. Employers should be aware of the PED coverage offered under the group health insurance plan.  

Can PED be covered under group health insurance from day one? 

Yes, some insurance companies offer coverage for pre-existing diseases from day one of the policy. However, the premiums for such policies are usually higher. 

 Why is it important to declare a pre-existing disease? 

When purchasing health insurance, it is essential to declare any pre-existing disease to ensure that your claim is not rejected by the insurance company. Health insurers issue policies in good faith and failing to disclose existing medical conditions may result in claim rejection or even policy cancellation. It is best to declare the condition, wait for a few years, and then begin receiving coverage for the said condition. 

Important things to know about pre-existing medical conditions: 

  • Every insurance company has a different pre existing condition waiting period  
  • Minor ailments such as flu, cough, cold, and fever are not considered pre-existing conditions. 
  • It may take 2-4 years to avail coverage for pre-existing diseases and their associated medical conditions. 
  • Some group health insurers offer coverage for pre-existing diseases from day one.
  • Concealing pre-existing diseases can lead to claim rejection, increased premiums, or policy cancellation. 
  • Ailments such as high blood pressure, cholesterol, and diabetes are considered pre-existing conditions. 
  • Any condition diagnosed within 4 years prior to policy purchase is considered pre existing disease. 

 Pre-existing diseases usually include conditions such as cancer, outpatient department (OPD) expenses, asthma, sleep apnea, obesity, and more. 

The coverage offered under each group health insurance plan varies, so it is crucial to review the policy’s terms and conditions provided by the employer to understand the extent of coverage offered. 

How are pre-existing medical conditions covered under group health insurance? 

Group health insurance is usually issued without requiring a medical check-up, making it easier to obtain coverage. Hence, pre-existing condition

are automatically covered. Some group health insurers may require employees to declare any pre-existing conditions before providing coverage. In contrast, when purchasing individual health coverage, the policyholder is often required to undergo a medical check-up or wait for a specific period before availing coverage. 

Is a medical check-up required when purchasing group health insurance? 

Generally, group health policies do not require a medical check-up to avail coverage. However, if a pre-existing disease exists, the insurer might request a medical check-up to assess the severity of the condition and adjust the premium accordingly. 

Should one choose a pre-existing disease waiver? 

As an employer, you can opt for a pre existing disease waiver if your base group health plan does not provide coverage for pre-existing conditions. Choosing the waiver ensures that your employees are covered for all pre-existing diseases without undergoing a medical check-up. 

If an employee has a pre-existing disease and leaves the job, they can convert the group health policy to an individual policy within 45 days before leaving. Continuing with the same insurer will ensure that the employee does not have to serve the waiting period again and can continue receiving the same benefits mentioned in the policy. 

Providing group health insurance that covers pre-existing diseases demonstrates your genuine concern for your employees’ well-being. It is always best to understand the coverage that employees are seeking to offer comprehensive coverage to them. 

Modern times, modern requirements 

The scope of group health insurance has expanded beyond hospitalization coverage. Employers now aim to offer a range of benefits to employees, including wellness benefits such as teleconsultation, pharmacy discounts, rewards for completing fitness tasks, and specialized sessions on wellness and mental health.

At Onsurity, we provide a healthcare membership that offers a host of benefits, ensuring the complete physical and mental well-being of your employees. 

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