Understanding The Pre-Existing Disease Clause

Anand Sharma, 42, leads a busy life and has a dedicated yearly renewal insurance policy for his family and him. Past month he suffered from a minor heart problem and had to be treated for it. When the time came to reimburse the treatment amount through his mediclaim policy, his insurers rejected the claim. It was stated that Anand was treated for hypertension 5 years ago, and the heart problem is the relating pre-existing disease. This rejection, of course, was wrongly based.

In such cases, it is hard to differentiate the ailments. To set the record straight and to bring clarity in the interest of the consumers, General Insurance Council of India (GIC) created new standard definition for pre-existing diseases that will have to be followed by health insurance companies.

The Definition

GIC definition states “The benefits (of any type of health insurance) are not available for any condition, ailment or injury or related condition for which the insured had signs or symptoms, and/or was diagnosed and/or received medical advice/treatment, prior to the inception of the first policy, until 48 consecutive months of coverage have elapsed after the date of inception of the first policy.”

This means that if a person with any condition, ailment or injury has symptoms or signs that were diagnosed or has received medical advice within 48 months before the policy issuance, he is not eligible for claiming reimbursement against such treatment. He can only get the claim once the 48-month waiting period, from date of policy issuance, lapses.

The Waiting Period

health insurance plans come with a waiting period for the pre-existing diseases. These are provisions created to avoid fraudulent claims by the insured. It also safeguards the insurers from losses of unethical claims and protects the interest of genuine claims.

The pre-existing waiting period usually lasts from 2 to 4 years and vary across insurers. In case the person undertakes a treatment for a disease or ailment, he is covered post the waiting period completion and the coverage comes into effect.

The policy wording will be a better guide to ascertain the duration of the waiting period.

False Disclosure

Your claim will only be valid if you have made true disclosure of your ailments and health conditions during the policy purchase. If you have failed to disclose an ailment having knowledge of its existence, your policy will be considered null and void. Omitting health conditions is a sure way to get your claim rejected and would be considered as misrepresentation of facts.

In case the person during time of policy purchase is unaware of suffering from an ailment or disease and declares that they are medically fit, the insurance company will reimburse the claim in true faith only after completion of the prescribed waiting period.

Things To Keep In Mind

• Study the policy carefully before purchasing it. Go through clauses similar to pre-existing diseases especially if your family has a medical history that is listed in the document. Keep a close look out for the sub-limits disclosed.
• Avoid switching health policies, in such cases your waiting period will be reset to zero and you will have to wait it out to claim any benefits. In case of policy transfer to a new insurance provider, clarify the waiting period duration and other benefits that might be reset on migration.
• Although 48 months waiting period is standard for pre-existing diseases, some insurers may offer policies with shorter waiting period, check with your policy advisor before signing the dotted line.
• As with every policy, clarify any and all doubts before investing in health insurance. Failure to do so could create grounds for rejection in future. Make sure to comb through the policy wording and schedules carefully.