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Insurance Article

NotFAQs: What do you need to know about pre-existing diseases and pre-existing conditions for your health insurance policy?

September 01 2020
Everything you need to know about pre-existing diseases
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If you are here, you have probably decided to do the smartest thing for your savings – buying a health insurance policy. Although, you would do your share of research to find a health plan that suits your needs, you could find the fine print confusing and may need clarity when it comes to understanding coverage for pre-existing diseases or pre-existing conditions, especially if you happen to have one. Read on as we take you through everything about pre-existing diseases and their coverage under a health insurance policy.

What do you mean by pre-existing disease (PED)?

A pre-existing disease is defined by the regulator as any condition or ailment

  • That is/are diagnosed by a physician within 48 months prior to the effective date of the policy issued by the insurer or
  • 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 or its reinstatement.
  • A condition for which any symptoms and or signs if presented and have resulted within three months of the issuance of the policy in a diagnostic illness or medical condition

So let’s say if you bought a health plan today but were diagnosed with diabetes prior to policy purchase, then diabetes becomes your pre-existing disease. While diabetes, asthma, hypertension, cardiac conditions, etc. are some common PEDs, something like a regular cold, cough or mild fever or infectious diseases like dengue and malaria are not considered as a PED.

Will you cover my pre-existing disease from the first day of my health insurance policy?

If we accept your proposal post medical evaluation, we will cover your pre-existing disease after 24 months of continuous coverage for a policy with a sum insured ₹3 lakh, and after 48 months of continuous coverage for a policy with a sum insured up to ₹2 lakh.

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

You must disclose your complete past and current medical history at the time of applying for a health insurance policy with us.

Can I declare my pre-existing disease after I have bought your health insurance?

No, pre-existing diseases need to be declared while buying health insurance because your policy is underwritten based on your health declaration. In case the same is not disclosed, we reserve the right to cancel the policy on grounds of misrepresentation. Furthermore, we shall not be liable for claims if any.

Also read: NotFAQs: Under What Circumstances Can My Health Claim Get Rejected?

Why is it so important to tell you that I have a pre-existing disease beforehand?

We cover your health under the principle of “utmost good faith.” This means we trust you for the information provided and believe it to be true. As a result, if you provide any false information or hide your pre-existing disease, it will mean a breach of trust. This can further lead to your claim getting rejected and your policy being cancelled.

What happens to my waiting period for pre-existing diseases if I fail to renew my policy in time?

If you fail to renew your health policy on time, the policy expires and with that all the renewal benefits and accrued additional sum insured earned through continuous renewal expire as well. You would need to buy a fresh policy wherein there will be fresh waiting periods for PEDs.

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

No, you will have to wait as per the period mentioned in your policy before we start covering your pre-existing disease.

Do you process a claim for pre-existing disease differently?

We thoroughly review every claim before processing it. But, if it is a claim for pre-existing disease in a scenario where the waiting period for that pre-existing disease is not yet completed with us, then the claim may be rejected.

Do I need to submit any special document while claiming for my pre-existing disease after I have completed the waiting period for it?

We only seek relevant information from you for processing any claim. In some cases, we require additional information to ascertain the onset of a pre-existing disease.

If I port my health policy from another insurer to you, what happens to the waiting period for my pre-existing disease?

If we accept your proposal, you will receive continuity benefits for your pre-existing disease under the ported policy.

Thus, when it comes to getting your health covered for pre-existing diseases, it is important to be transparent and truthful with your declaration. Sometimes you may genuinely forget mentioning a small surgery done in the past, but this one error could cost you an approval for your claim later. So make sure you declare any pre-existing diseases or conditions when you buy health insurance. Don’t try to hide it, thinking you would be denied health insurance. It can defeat the purpose of having your health secured when your claim will be rejected on the grounds of non-disclosure of pre-existing diseases. A true disclosure can prove to be a win-win situation for you as well as your insurance company.

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