How Does Health Insurance for Existing Conditions Work?

Health insurance for existing conditions provides coverage against illnesses diagnosed before the policy coverage starts. In this context, insurers require a waiting period of two to four years before covering these conditions.

However, according to the Insurance Regulatory and Development Authority of India (IRDAI) regulations 2016, policyholders must inform the insurer about the pre-existing condition at the time of underwriting. Non-disclosure may lead to exclusion of policy coverage. Furthermore, the regulation also highlights that conditions such as Malignant neoplasms, epilepsy, cerebrovascular diseases or stroke are permanently excluded from health insurance cover.

To know more about the pre-existing disease waiting period and the consequences of non-disclosure, read on.

What is a Pre-Existing Condition in Health Insurance?

According to the Insurance Regulatory and Development Authority of India (IRDAI), a pre-existing condition (PED) refers to a medical condition, injury, or disease for which an individual is undergoing treatment up to 36 months before a health insurance policy purchase. This includes diabetes, cancer, thyroid, asthma, hypertension, etc.

Usually, health insurance policies impose a specific waiting period before offering coverage for such conditions. During this waiting period, the policyholders cannot make a claim. It is essential to disclose if a policyholder suffers from a pre-existing condition at the time of policy purchase to eliminate the chances of claim rejection.

What is the Waiting Period for Health insurance for existing conditions?

The waiting period refers to the duration which the policyholder has to complete before availing health insurance coverage. It usually ranges between 2 and 4 years and is applicable in the context of pre-existing health conditions. Insurance experts suggest buying a health insurance policy with a minimal waiting period so that obtaining coverage is possible soon.

Types of Waiting Periods for Health Insurance Plans

To determine the time when you can begin receiving claim benefits, there are different types of waiting periods. These are:

1. Initial Waiting Period: 30 days starting from the day of policy purchase, except for accidents.

2. Pre-Existing Disease: Ranges between 2 and 4 years and varies among insurers.

3. Specific Disease Waiting Period: Patients suffering from hernia, arthritis, and ENT disorders may have to wait 1 to 2 years even when these conditions are not pre-existing.

4. Maternity Waiting Period: Ranges between 9 months and 4 years.

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Effects of a Pre-existing Disease on Your Health Insurance

When a policyholder has a pre-existing health condition, it directly impacts the policy premium and delays coverage. This means the policyholder has to wait for a certain period before they can make a claim. The effects of a pre-existing disease on health insurance include:

1. Higher Premiums: The policy premiums may go up due to higher health risks.

2. Waiting Periods: Policyholders have to wait for at least 2 to 4 years before availing policy benefits.

3. Coverage Restrictions: Some policies may limit or exclude coverage for specific PEDs altogether.

4. Medical Underwriting: Insurers may ask policyholders to undergo medical tests to assess associated risks before approving the coverage.

Please note: Bajaj General Insurance offers comprehensive plans with manageable waiting periods, making it easier for policyholders with PEDs to get coverage.

Consequences of Non-Disclosure of Pre-existing Diseases

If you are wondering, “What happens if I don’t disclose pre-existing conditions?” Let us give you an example for better understanding. Imagine a policyholder is hospitalised after meeting with an accident.

Since he has health insurance coverage, they are worry-free. Suddenly, they find their claim was rejected since the insurer did not have any idea that the policyholder had been suffering from diabetes for the last five years. This is the consequence of non-disclosure.

Meaning, non-disclosure of pre-existing diseases to your insurer may lead to:

1. Rejection of the claim if the treatment involves an undisclosed illness.

2. Policy cancellation, which might leave you uninsured.

Now, if you want to know “How to disclose pre-existing disease in health insurance?”, follow these steps:

Step 1: At the time of filling out your insurance proposal form, clearly list all kinds of past illnesses or health conditions.

Step 2: If you have undergone surgeries or treatments, mention the dates and years.

Step 3: Mention if you are currently undergoing any specific medication or treatments.

Step 4: Disclose if you smoke or drink (lifestyle habits).

Step 5: Attach all the supporting documents.

Step 6: If the insurer asks, take pre-policy medical screenings.

Step 7: In case you are unsure about your past ailments, or how to disclose that information,  contact the insurer. 

List of the Most Commonly Asked About Pre-Existing Conditions in Proposal Forms

At the time of policy underwriting, insurers ask for full disclosure of all kinds of medical conditions of a policyholder. Such information is crucial for an insurer to evaluate a policyholder’s risk profile, the waiting period and determine the premium rates based on that.

Here is a list of the most commonly asked questions about pre-existing conditions when it comes to health insurance for existing conditions:

1. Diabetes

2. Hypertension

3. Thyroid

4. Asthma

5. History of cardiovascular diseases

6. Neurological disorders such as epilepsy

7. Chronic kidney disease

8. Cancer

9. Major organ transplants

10. Past surgeries

11. Liver disorders

12. Gallbladder disease

Do’s and Don'ts in Case of Health Insurance for Existing Conditions

Having an understanding of what to do and not to do will help you to plan your healthcare requirements more effectively:

Coverage Options in Health Insurance for Pre-Existing Conditions

After the waiting period is over, health insurance for pre-existing conditions provides a wide range of benefits, including hospitalisation expenses, specialised treatments, and medication costs related to pre-existing diseases. Even though this cover increases the premium, the financial protection and peace of mind it provides are invaluable.

Coverage options in health insurance for existing conditions include:

Hospitalisation Cover After Waiting Period

Once the waiting period of 2 to 4 years is over, policyholders can receive hospitalisation coverage under both cashless and reimbursement benefits.

Customised Plans

Insurance companies evaluate policyholders’ health history and request them to undergo medical tests. Based on the findings, they determine the coverage amount, policy terms and premium.  

Transparency in Disclosure

While choosing a pre-existing health insurance cover, it is important to ensure transparency. Misinformation or incomplete information may lead to claim rejection.

Add-on covers

Certain pre-existing health insurance plans allow policyholders to opt for additional coverage, such as critical illness, and a reduced waiting period. Whereas the critical illness cover offers a fixed lump sum when a critical life-threatening disease is involved, a reduced waiting period enables policyholders to shorten the standard waiting period.

Tips to Buy Health Insurance If You Have a Pre‑Existing Disease

Follow these tips while choosing a health insurance plan with pre-existing conditions:

1. Understand how policy terms and conditions change when a pre-existing health condition is involved.

2. Disclose everything related to a pre-existing health condition to the insurer, as it could have a direct impact on claim settlement.

3. Look for insurers that offer shorter waiting periods or add-ons that can reduce the waiting period.

4. Review the copayment options carefully as these may reduce the premium but can increase out-of-pocket charges.

5. It is ideal to choose a comprehensive cover with a higher sum insured amount as this keeps you financially protected against consistently rising healthcare costs.

Final Words

A pre-existing health insurance plan is crucial for individuals suffering from existing health issues before purchasing a policy. While choosing such cover from an insurer, it is mandatory to consider coverage limit, waiting period, network hospital availability and additional benefits such as wellness programs.

Insurance experts recommend comparing various health insurance plans from different insurers to choose the most suitable plan that fits your budget. Moreover, go through the policy fine print and understand the policy terms and conditions, as it will help you make an informed decision.

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Frequently Asked Questions

How are pre-existing conditions determined?

Insurance companies review the policy applicant’s past medical history, treatment, medical reports and diagnosis while determining the pre-existing conditions, premiums and associated waiting period. 

Does a pre-existing illness have any impact on the amount of coverage?

Yes, usually when a pre-existing illness is involved, the policy premium goes higher, and the policyholder has to complete a waiting period before the policy coverage kicks in.

What is a pre-existing disease before 48 months?

A pre-existing disease before 48 months refers to a medical condition, injury or illness for which a policyholder is receiving treatment before purchasing a health insurance policy.

What is a serious pre-existing condition?

A serious pre-existing condition refers to a severe, long-term and chronic health issue such as cancer, heart disease, or diabetes.

What is the difference between pre-existing diseases and medical history?

Pre-existing diseases refer to active health conditions that have been diagnosed before purchasing health insurance. In contrast, a medical history refers to the comprehensive record of your overall health, including your childhood illnesses and past surgeries.

Can I get coverage for a pre-existing disease after a specific period?

Yes, you will get coverage for a pre-existing disease as soon as the waiting period is over. Usually, the waiting period ranges between 2 and 4 years, but it varies from one insurer to another.

How can I ensure a smooth claims process for a pre-existing disease in health insurance?

To ensure a smooth claims process for a pre-existing disease in health insurance, it is crucial to disclose all the information related to the condition accurately to the insurer at the time of purchasing a health insurance policy.

Is there a way to skip the waiting period for pre-existing diseases?

Yes, you can skip the waiting period for pre-existing diseases simply by choosing a specific policy option. However, skipping the waiting period may increase your policy premium significantly.

When do I need to tell the insurer that I have a pre-existing disease?

It is mandatory to inform your insurer about a pre-existing disease at the time of policy purchase. This way, the insurer can properly evaluate the associated risks and determine the premium.

Disclaimer: The content on this page is generic and shared only for informational and explanatory purposes. It is based on several secondary sources on the internet and is subject to changes. Please consult an expert before making any related decisions.

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