“Pre-existing diseases” in health insurance refers to any condition or disease that an individual has prior to purchasing a health insurance policy. When you plan to buy a health insurance policy, it is necessary to disclose all relevant medical conditions to the insurance company. This information must be properly disclosed and filled out in the “proposal form,” a document you have to fill for getting a health insurance policy. The majority of health insurance claim rejections occur because these pre-existing diseases (PEDs) are not disclosed to the insurance company. This article delves into this issue in detail.
IRDAI definition of Pre Existing Diseases
The Insurance Regulatory and Development Authority of India (IRDAI) publishes annual reports on insurance which also include review of grievances received in a financial year. This is an area where claim rejections and grievances are most frequent. To address this, IRDAI has issued guidelines to clarify the term and prevent its misuse by insurance companies.
IRDAI first defined PEDs in its “Guidelines on Standardisation of Exclusions in Health Insurance Contracts” and later amended this definition on February 10, 2020, through circular “IRDAI/HLT/REG/CIR/046/02/2020.” According to the amended definition:
Pre-existing Disease means any condition, ailment, injury, or disease:
IRDA definition of PED, 10.02.2020
a) That is/are diagnosed by a physician within 48 months prior to the effective date of the policy issued by the insurer or its reinstatement, or
b) 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.
Before proceeding, it’s essential to understand the details of this definition. The IRDAI’s definition of PED includes not just “diseases” but also “conditions,” “ailments,” and “injuries.”
Condition: This refers to any abnormal health condition, such as chronic asthma, which must be declared in the proposal form before purchasing the policy.
Ailment: Refers to minor illnesses, like the common cold.
Injury: Includes physical injuries, like an ankle injury.
Disease: Often serious health conditions caused by internal or external factors, such as cancer or arthritis.
The IRDAI mandates that you must declare all these conditions, regardless of severity, as long as they existed within 48 months before purchasing the insurance policy.
Declaring Pre existing disease to insurance company
It is important to disclose any medical history before purchasing an insurance policy. When you report a pre-existing condition, the insurance company may respond in different ways.
Deny the Health Insurance Policy: An insurance company may deny coverage based on a pre existing disease or condition. For example, if a person has chronic kidney disease that requires dialysis and wants to buy health insurance, the insurance company will most likely deny the policy.
Issue Policy with PED waiting: The insurance company may accept the proposal and your declaration on disease history and offer you a policy with a waiting period for the declared and accepted PED.
For example, if someone has a “kidney stone,” the insurance company may cover the individual but exclude the coverage of treatment and complication related to kidney stones for a specific period, known as waiting period for PED.
Issue Policy with PED waiting period and loading on premium: Some policies, like the New India Yuva Bharat policy, may apply a loading on the premium, such as a 2.5% increase for conditions like “High BMI,” “diabetes,” or “hypertension.” Coverage is available only after the pre-existing condition waiting period has elapsed.
Issue policy but exclude the PED Coverage Permanently: In some cases, the insurer may accept the proposal but exclude coverage for specific PEDs throughout the policy’s lifetime. For example, if someone has been deaf since birth, the insurance company might offer the policy but exclude coverage for hearing-related treatments for the entire duration of the policy.
Can an insurance company refuse to issue a policy to someone with a pre-existing condition?
The IRDA’s position on the insurance policies for people with pre-existing conditions is clear and unambiguous: it depends on the insurance company’s underwriting policies and product design. In simple terms, it is entirely up to the insurance company to decide whether to offer a policy to such individuals or to launch such insurance products that cover PED.
Offering health insurance coverage to any person who was already suffered / has been suffering from any disease / illness is subject to underwriting policy of an insurer. It is also to be informed that providing coverage for those persons who were cured of any specific illness / disease is subject to product design of the Insurers. Insurers design products keeping in view certain factors such as viability and self-sustainability of products and the needs of the intended target market segment.
Irda on PED coverage
Why don’t insurance companies cover pre-existing conditions from day one?
Pre-existing disease/s or condition which are chronic can have a long-term impact on an individual’s health. People with chronic pre-existing conditions are likely to be hospitalized more frequently than those without such conditions, leading to higher claim costs for the insurer.
Therefore to avoid the financial risk, insurance companies may either increase the premium, permanently exclude coverage for the pre-existing condition, or, in some cases, deny coverage altogether.
What If You Don’t Declare a PED?
If you have a disease or adverse health condition and purchase health insurance without disclosing it, your claim could be rejected, and the policy may also be cancelled on the grounds of misrepresentation or breach of “disclosure to information norm”.
The Policy shall be void, and all premium paid hereon shall be forfeited to the Company in the event of misrepresentation, mis-description, or non-disclosure of any material fact.
IRDA definition on Disclosure to information norm.
A claim may be rejected or a policy cancelled, even if you’re hospitalized for an illness not directly related to an undisclosed condition.
It’s not a good idea to hide a pre-existing disease/condition. You might pay premiums for years, only to have your policy cancelled later for not being upfront. Insurance companies have doctors who carefully review claims and investigate if they suspect you didn’t disclose something from your medical history when you bought the policy. If they find out, they can reject your claim or cancel your policy by using the “disclosure to information” clause.
What if you were unaware of a disease when buying the policy?
Some diseases are chronic and develop gradually, such as hernia, cataracts, or fistulas. These conditions might not be apparent when you buy the policy, which is why insurance companies generally impose a waiting period known as the “specific disease waiting period” for such conditions. All Health insurance policies include a list of conditions that will be covered after the waiting period, even if you didn’t disclose them because you weren’t aware they existed.
However, if a disease not listed as a specific disease develops after purchasing the policy, the insurance company may require you to provide your doctor’s consultation history. You may need to prove that the disease did not exist before the policy purchase or that you were unaware of its existence.
New IRDA guidelines on waiting period for PEDs
Many people think that all their existing conditions, whether disclosed or not, will be covered after the pre-existing condition (PED) waiting period. But this isn’t true. Only the conditions you declare and the insurance company accepts will be covered after the waiting period. However, the IRDA has set a maximum waiting period for covering pre-existing conditions.
According to the IRDAI’s “Master Circular on Standardisation of Health Insurance Products” dated July 22, 2020, the maximum waiting period for PEDs in a health insurance policy can be 48 months. However, as per the latest IRDAI (Insurance Products) Regulations, 2024, effective from April 1, 2024, the maximum waiting period for PEDs has been reduced to 36 months.
However, the the IRDA guidelines to reduce the maximum waiting period from 48 months to 36 months are yet to be implemented by insurance companies. They will need to update all health products to align with this new waiting period.
Medical insurance for pre existing conditions
If you have a pre-existing condition and are looking for a health insurance policy, finding one with a zero waiting period is almost impossible. Some insurance companies, like Narayana Health Insurance’s “Aditi” policy, claim to offer zero waiting periods, but in reality, the waiting period ranges from NIL to three years, depending on the outcome of a pre-policy medical check-up.
Only group health insurance policies offered by employers to its employees, typically have zero waiting periods. These are tailor-made policies where the terms and conditions are decided by the employer and are generally not available to individuals outside of such groups. Government-sponsored health schemes, like the Ayushman Bharat scheme, also typically have zero waiting periods for PEDs. But again coverage under these schemes is available for the people belonging to a particular strata or decided by government policies.
How to Get an Insurance Policy If You Have a Pre-Existing Disease
Getting an insurance policy when you have a pre-existing condition can be challenging. Even though the IRDAI has regulations that require insurance companies to provide coverage for all kind of medical conditions, insurance companies are often hesitant to cover individuals with existing health issues. Private insurers are sometimes criticized for favoring low-risk individuals—those who are young, healthy, and have no medical history—while denying coverage to older people or those with chronic conditions. This can make securing insurance with a pre-existing condition frustrating. However, there are some strategies you can use to improve your chances of getting coverage.
Tips for Securing Health Insurance with a Pre-Existing Condition:
- Always Declare Your Medical History: Be upfront about your medical history when filling out the proposal form. Not disclosing this information can lead to years of paying premiums only to have your claims denied later.
- Explore Multiple Insurance Companies: There are 28 general and standalone health insurance companies. If one denies you coverage, another might accept you based on their underwriting guidelines. If a large sum insured policy is denied, consider applying for a smaller policy, such as one with a 1 lakh sum insured. You can also consider getting multiple smaller policies from different insurers to ensure adequate coverage.
- Consider Top-Up or Super Top-Up Policies: If you can’t get a standard policy, try applying for a top-up or super top-up policy with a deductible limit. These policies are easier to obtain. With these, you’ll be responsible for costs up to the deductible limit, and the insurance company will cover expenses beyond that amount.
- Look for Disease-Specific Policies: Some insurance companies offer policies tailored for specific conditions, like diabetes. These policies may have higher premiums but can provide coverage for people with chronic conditions.
- Build Your Own Emergency Fund: If you’re unable to get any insurance coverage, it’s wise to create your own emergency fund for medical expenses. This can help you manage unexpected healthcare costs.
By following these steps, you can improve your chances of getting health insurance coverage even with a pre-existing condition.
How to prevent claim rejection due to a pre-existing condition?
To avoid claim rejection due to a pre-existing condition, consider these precautions:
- Fill the proposal form with utmost honesty: When you’re buying health insurance, the proposal form is key. It is your declaration of your health status, and any mistakes or omissions can lead to your claim being rejected or your policy being canceled. Insurance companies rely on principal of “utmost good faith,” meaning you are expected to be completely honest, and insurance company should be clear about the policy’s terms, exclusions, and limitations. If you don’t disclose relevant information or provide incorrect details, it can cause trouble in future.
To protect yourself, make sure to fully and accurately disclose all relevant medical information when filling out the proposal form. Although IRDAI guidelines say you need to report any pre-existing conditions from the last 48 months, not all forms make this clear. To avoid any headaches later on, fill out the proposal form honestly and keep a copy for your records. - Choose a Policy with a Pre-Policy Health Check-Up: opt for a health insurance policy that requires a mandatory pre-policy check-up. This makes it harder for the company to reject claims based on undisclosed pre-existing conditions.
- Conduct a Self-Check-Up: If the policy doesn’t require a health check-up, consider getting one yourself and keep the records. This can help in case of future disputes.
- Inform the Insurance Company of Any New Conditions: If you discover a health condition after purchasing the policy, notify the insurance company immediately. This allows them to adjust your premium or coverage, and prevents issues with future claims. Hiding this information could lead to claim denial.
Material change: The Insured shall notify the Company in writing of any material change in the risk in relation to the declaration made in the proposal form or medical examination report at each Renewal and the Company may, adjust the scope of cover and / or premium, if necessary, accordingly
IRDA Master Circular on Standardization of Health Insurance Products (22nd July, 2020)
- Appeal if Your Claim Is Rejected: If a pre-existing condition is discovered after you have purchased the policy and your claim is rejected, you may need to prove that you were unaware of the condition. In such cases, you can appeal to the Ombudsman or a consumer forum for help.
Policies with PED Waiting Periods
Policies with shorter waiting periods for PEDs are generally considered better, but the waiting period should not be the sole criterion when selecting a health insurance policy. It’s essential to evaluate the policy comprehensively, including coverage and exclusions.
Here is a list of insurance policies with pre-existing condition waiting periods.
Star Health Insurance pre existing disease waiting period
Star Health Insurance provides a variety of health insurance plans designed to meet the needs of different age groups and sections of the population. For pre-existing conditions that have been disclosed by the policyholder and accepted by Star Health, the waiting period can range from 12 to 48 months.
| Star health insurance | Waiting period for pre-exisating diseasese (Declared and accepted) |
|---|---|
| Star Comprehensive Insurance Policy | 36 months, optional cover to reduce PED to 12 months only |
| Medi Classic Insurance Policy (Individual) | 48 months |
| Super Surplus Insurance Policy | 36 months |
| Star Health Gain Insurance Policy | 48 months |
| Star Net Plus | 48 months |
| Star Health Premier Insurance Policy | 24 months |
| Family Health Optima Insurance Plan | 48 months |
| Senior Citizens Red Carpet Health Insurance Policy | 12 months |
| Young Star Insurance Policy | 12 months |
| Star Women Care Insurance Policy | 24 months |
| Star Health Assure Insurance Policy | Policy term 3 yrs -30 months, Policy term1/2 yrs – 36 months |
ICICI Lombard pre existing diseases waiting period
| ICICI Lombard | Waiting Period |
|---|---|
| Health care Plus | 48 months |
| Health Booster | 24 months |
| Smart super health insurance | 48 months |
| Elevate | 36 months |
| Health AdvantEdge | 24 months |
| Golden Shield | 24 months |
| Complete Health Insurance | 24 months |
| Health Shiled | 12/24 months as per plan opted |
| I shield | 48/36/24 months |
| Max Protect | 24 months |
I hope this clears all the confusion regarding pre-existing disease condition in health insurance policies. Still if you have any query, feel free to ask in comment section.
