Pre-Existing Diseases in Health Insurance Policy

What Are Pre-Existing Diseases in Health Insurance?

According to the IRDAI, pre-existing diseases are any condition, ailment, injury, or disease diagnosed or for which treatment was received within 48 months before the effective date of policy issuance or reinstatement by the insurer.

As per IRDAI guidelines, pre-existing conditions such as diabetes, hypertension, asthma, and heart conditions now have a maximum waiting period of 3 years in India. Insurers will review your medical history, including past treatments and medications, and may require a medical check-up to determine premiums and coverage terms before issuing the policy.

List of Pre-Existing Diseases in Health Insurance

Common Health Issues

Here are some examples of common health issues considered as pre-existing diseases.

• Asthma
• BP
• Cholesterol
• Diabetes
• Thyroid
• PCOD
• Mental health condition
• Anaemia
• Fatty liver
• Obesity
• Fibroid

Major Surgery

Here are some examples of major surgeries considered as pre-existing diseases.

• Heart Surgery
• Brain Surgery
• Cancer
• Organ Replacement
• Rheumatoid Arthritis
• Neurological Disorders
• Parkinson’s Disease
• Alzheimer's

Minor Surgery

Here are some examples of minor surgeries considered as pre-existing diseases.

• Hernia
• Stone
• Cataract
• Ligament Surgery
• Knee replacement
• Cyst
• Fracture, etc.

How Insurers Evaluate Pre-Existing Health Conditions

Insurers evaluate your pre-existing conditions by reviewing the medical declaration form you submit, which discloses all details of past diagnoses, treatments, and ongoing medications. They also review past reports or prescriptions to determine the duration and control of any pre-existing condition. Insurers use this information to categorise applicants according to their risk profile, which determines coverage, premiums, policy exclusions, and waiting periods for covered PEDs.

In some cases, the insurer may recommend add-ons such as critical illness cover to ensure appropriate coverage.

Waiting Period for Pre-Existing Diseases

The waiting period for pre-existing diseases depends on the specific condition covered by the insurer. The Insurance Regulatory and Development Authority of India (IRDAI) has set a maximum waiting period of 3 years for any pre-existing disease.

Different insurers have varying waiting periods for pre-existing diseases, determined by the following factors.

Type of Medical Condition

The type and severity of the illness/disease play a major role in determining the waiting period. For example, chronic conditions such as diabetes and hypertension usually have a longer waiting period compared to minor ailments.

Certain specific pre-existing diseases, such as cataracts, hernia, or joint replacements, have a fixed waiting period.

Policy Type and Coverage

Some health insurance policies may reduce the waiting period for PEDs by charging an extra premium or offering specialised plans

Policy Renewal History

The waiting period applies only to continuous coverage. If your policy lapses due to missed premium payments, the entire waiting period will be reset. This would disrupt your coverage and leave you unprotected against medical expenses incurred due to PEDs.

Initial Waiting Period

Every health insurance policy has a standard waiting period regardless of the type of plan or PEDs. The standard waiting period is included in the waiting period for PEDs

How Pre-Existing Diseases on Health Insurance Affect Premiums

The type and severity of pre-existing diseases significantly affect premiums for health insurance plans. Here’s how pre-existing diseases impact your premiums.

- Higher Premium

Pre-existing diseases may make you a riskier candidate, which could lead the insurer to apply a higher loading rate to policy premiums, increasing the total cost to cover potential future claims. However, if PEDs are well managed and controlled, you may be charged a lower premium than for unmanaged illnesses.

- Longer Waiting Period

Longer waiting periods are imposed on PEDs during which you are responsible for paying all medical expenses incurred for those conditions.

- Reduced Coverage

Some health plans may charge a higher premium but limit the coverage or set sub-limits on expenses related to pre-existing diseases.

FAQs

What are pre-existing diseases?

Pre-existing diseases are medical conditions, illnesses or injuries diagnosed or for which treatment received within 48 months before the effective date of the insurance policy.

Is it necessary to disclose all pre-existing diseases to the insurer?

Yes, you must disclose all pre-existing diseases and your past medical history to the insurer to ensure complete transparency. Failing to disclose these may result in your policy being cancelled or rendered void.

Do pre-existing diseases impact premiums?

Yes, pre-existing diseases can increase your premiums depending on their severity and how well-managed they are.

What is the waiting period for pre-existing diseases?

The waiting period for pre-existing diseases varies depending on their type and severity; IRDAI has set a maximum waiting period of 3 years for any pre-existing condition.