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Pre-existing Diseases Cover: An Important Claus in a Health Insurance Plan

Health Insurance assures the policyholder to compensate for the expenses incurred on the treatments as mentioned in the policy. It includes both accidental and illness related hospitalization expenses. A health insurance plan can repay these medical expenses that are incurred due to injury or illness. Reimbursement can be done either directly to the hospital or the policyholder.

What is the need for Health Insurance Plans?

With an escalation in the healthcare costs every year to double figures, a need arises for an individual to find financial support to arrange for finances at the last moment.

Health insurance enables us to secure the future of the insured in both health and monetary terms. The insured can also claim tax exemption benefits on the premium paid for a health insurance plan. Thus, health insurance plans play a significant role in an individual's life, which is solely responsible for the family's financial health, especially during this pandemic.

Health Insurance for an Individual with a Pre-existing Disease 

Since health insurance coverage has become almost inevitable post COVID-19 outbreak, many people are considering buying them. But for people with pre-existing conditions, getting coverage under a health insurance policy can sometimes get challenging. There are certain limitations to get insurance coverage in case you have a pre-existing illness. The insurer might ask you to undergo pre-medical screening before policy issuance.

Let us first understand what is a pre-existing illness or medical condition.

 What is a Pre-existing Illness or a Disease?

A pre-existing illness or disease refers to a health condition or ailment or injury that already exists at the time of purchasing a health insurance plan. These pre-existing diseases or PEDs are usually not included in the policy coverage benefits until the completion of the given waiting period. The maximum waiting period can be four years for such PEDs.

Examples of Pre-existing Illness or Condition

The pre-existing conditions can include health ailments like high cholesterol, high blood pressure, diabetes, thyroid, asthma, cancer, sleep apnoea, COPD, and so on. They are included in this list because of their chronic or long-term nature. 

For How Long Does a Pre-existing Condition Last?

Usually, the insurers are reluctant to cover pre-existing medical conditions for up to the first twelve months of the purchase, or eighteen months in the late acquisition of a health insurance plan.

Moreover, if a person is receiving medical advice or undergoing a treatment at the time of policy purchase, it is also known as a pre-existing health condition. 

IRDAI has now come up with a new definition of pre-existing diseases, which is for the benefit of the customers. Accordingly, a pre-existing disease means any health condition that has been diagnosed before the date of the policy issued by the insurance company or its reinstatement.  As per the recent regulations by the IRDAI, people who have paid medical insurance premium for more than 8-years cannot be denied claim.

What Exactly Determines a Pre-existing Health Condition?

According to the standard definition, a pre-existing health condition is a condition where the patient is already receiving medical advice or undergoing treatment before purchasing a new health insurance plan.

Why do the Insurers Dislike a Pre-existing Condition?

Insurers are often reluctant to provide insurance coverage to those who are suffering from pre-existing health conditions as such people incline to require treatment and filing a claim earlier for the reimbursement. Thus, such people pose a higher financial risk to insurance companies. 

It is complicated to predict whether a healthy person is sick or may get sick. In such a case, an insurance company has to be alert and in the knowledge of the people who are already suffering from various health problems. The only reason behind this alertness is that insurance companies are here to run a profitable business, after all.

How to get Health Insurance with a Pre-existing Health Condition?

People with a pre-existing health condition often have to go through various medical tests and health examination procedures. This medical examination often results in cancellation of insurance coverage, refusal by the insurance company to reimburse medical bills or even an outright rejection of a Health Insurance Plan. 

Then in which way can an individual with a pre-existing health condition buy a Health Insurance Plan? Let us have a look at the different ways in which this is possible –

Different Insurance Companies have Distinct Policies

Although it is very gruelling to buy a health insurance plan for an individual with a pre-existing health conditions, all insurance companies do not behave similarly. Some insurance companies consider an individual's entire medical history before determining any medical condition. While the other insurers consider the medical records of an individual over the last few years (usually 3 to 4 years). 

Every Consultation or Visit to the Doctor does not Matter

Insurance companies take into consideration only those ailments or health conditions that are chronic or, in simple words, have a long-term effect. Thus, if an individual is prone to flu, cough, cold, and fever every winter, even then, he or she doesn't need to worry. These regular illnesses are left out or instead not taken into consideration by the insurance company as they are of short-term effect. 

Hiding a Pre-existing Condition

An individual should avoid obscuring the insurance companies of any pre-existing health condition because if the insurer comes to know of such an illness at the time of the treatment, then there are chances of the rejection of the claim by the insurer. 

Coverage for Pre-existing Illnesses

There is a misunderstanding among people that there is no insurance coverage for pre-existing illness in a health insurance plan. However, this is not true. Usually, there is a condition of a waiting period for pre-existing health conditions. During this period, an individual requires to wait for reimbursement until the period ends. During this waiting period, however, expenses incurred from the treatment of other illnesses will be reimbursed under the health insurance plan.

Also, one must remember that during the waiting period, doctor visits, medical bills, and treatment charges towards any pre-existing ailments will not be covered under a health insurance plan. 

To Work Around the Waiting Period

Most of the health insurance plans have a specific waiting period refraining a policyholder from filing a claim. This waiting period varies according to the insurance providers and the plan chosen.

Some policies have a waiting period of 48 months, while others may require 36 months for the same pre-existing health condition. It is, however, advisable to shift to a different health insurance plan only after the completion of this waiting period.

If a policyholder shifts to another insurance provider before the completion of the waiting period, he or she is likely to start a new health insurance plan with a late waiting period. Nonetheless, there are some policies that offer reduction of the waiting period by paying extra premium. 

Some insurance companies who offer health insurance plans come up with co-payment for pre-existing health conditions. The insured will have to pay some percentage of the amount, and the insured will pay the rest of the outstanding amount.

Therefore, an individual with a pre-existing health condition can also buy health insurance plans with the condition that he or she should inform the insurance company about such a health condition. Thus, it is just a matter of selecting the right health insurance plan and keeping the insurance company informed. 


Written By: Paisawiki - Updated: 11 February 2021

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