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Insurance terms and conditions regarding pre-existing illnesses

Rising costs of medical expenditure and high inflation rates have already made health insurance a necessity. But just buying health insurance is not enough anymore; you need to be sure that what you’re buying for you and your loved ones gives you foolproof protection against what you fear. Pre-existing diseases are one of the crucial things you need to consider while buying insurance. This article lays down all the points you need to know about pre-existing conditions which will help you in making an unbiased and intelligent insurance decision.

What is a pre-existing condition? 

Pre-existing conditions are those conditions which you may have or are already suffering from before buying an insurance policy. Examples of such illnesses can be diseases like cancer, diabetes, epilepsy and depression. It is one of the factors which would help you choose the right insurance policy that would give you not only money’s worth but also a sense of safety.

Things you should know about pre-existing conditions:

Here are some essential points which should be taken into consideration while applying for a health insurance plan with pre-existing diseases 

1. Different Insurers Have Different Policies:

All companies don’t follow the same rules when it comes to pre-existing disease insurance. Some insurers will cover a pre-existing disease while some will not. Some will have a reduced waiting period, while some will have an extended waiting period. Therefore, you should read the terms and conditions carefully before purchasing the plan.

2. Every Doctor Visit Is Not Counted:

You do not have to worry about disclosing common illnesses like cold or fever. Visiting a doctor to treat your headache isn’t a pre-existing illness. However, if you are under medication for more than a year witnessing continuous migraine, then it is considered as a pre-existing disease. So be sure to disclose such information.

3. Hiding a Pre-existing disease, not an option:

It is in your best interest, to be honest and transparent with your insurance provider regarding pre-existing conditions to avoid hassles during claim settlement. 

4. Pre-existing disease can be covered:

IRDAI does not provide any directives about not covering pre-existing diseases. So, Pre-existing conditions are covered once the waiting period is over. 

New modifications by the Insurance regulator

Insurance Regulatory and Development Authority of India (IRDAI) has eased up on some of the norms for pre-existing diseases which would benefit you as a policyholder. The change is made to the definition of a pre-existing condition, which now clears the confusions related to claim rejection and termination of policies.

Earlier, IRDAI defined pre-existing illness as “Pre-existing Disease means any condition, ailment or injury or related condition(s) for which there were signs or symptoms, and/or were diagnosed, and/or for which medical advice/treatment was received within 48 months before the first policy issued by the insurer and renewed continuously thereafter.” 

The use of this subtle sentence used to give insurance companies an upper hand, and they could deny you claim. 

But with the changes coming in, you have an edge. The new definition states pre-existing illness as 

“the illness which is/are diagnosed by a physician within 48 months before 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 before the effective date of the policy issued by the insurer.” This means that the insurance company cannot reject your claim because you developed an illness within or after three months of buying a policy.

What are the effects of pre-existing disease on your health insurance?

Are you suffering from a pre-existing disease? Here’s a list of repercussions that it might have on your health insurance policies. Different insurance companies might specify different additional clauses. Thus it is suggested to go through the respective policy wordings carefully before buying a health insurance plan. 

●    Premium Loading:

This means that the premium charges are going to be on the higher side. The premium will be loaded because the insurance firm is taking the danger of covering a pre-existing illness. Such premium loading is merely applicable at the time of buying the policy. It can’t be charged again if the policy is renewed on an ongoing basis with no break in between.

●    Waiting Period:

This is the period that you’ve got to attend before the policy covers the pre-existing illness. There is no standard waiting period. It depends upon the disease, the cover, and therefore the insurance company offering the policy. For example, if hypertension is said to be a pre-existing disease, the waiting period for it can be around 2 years. That means that the policy will cover Hypertension issues after 2 years from policy purchase date assuming there’s continuous coverage.

●    Premium loading and waiting period:

There will be situations where you will be charged a higher premium as well as have a long waiting period to cover illness. Such a situation may arise because of a severe condition like high hypertension.

●    Medical check-up:

In case you have a pre-existing disease, the insurance company will ask you to go for a medical check-up. The insurance premium will be decided based on the test results. There is a chance that the insurance company will refuse to offer a policy if the results are unfavorable.

●    Permanent Exclusion:

The insurance company may offer you insurance coverage but exclude the pre-existing disease from the claim. Here, you will have to agree that the mentioned pre-existing disease is a permanent exclusion from the policy. This way, you will be uninsured against an illness or disorder, but the premium shall be covered for other health scenarios based on the terms and conditions of the policy.

●    Denial of the policy:

The insurance company has the right to refuse to offer you insurance coverage based on pre-existing conditions. In such cases, they will deny your application for a health insurance policy.

Things to consider in case of pre-existing diseases:

●    Share information about pre-existing diseases with the insurer (if any):

Be transparent while communicating with the insurance company. 

●    Get a check-up:

It is a good idea to get a complete health check-up done beforehand, as it would let you know if you have any existing diseases and help you act on them promptly; thereby preparing you for the future well in advance.

●    Don’t withhold critical information

Insurance companies are your saviors who provide you with financial assistance during health emergencies. So, be transparent with the insurer. Do not hide any information about your medical history. 

●    Always compare plans before buying:

You might find a better policy with a good claim ratio which is charging you lesser premiums for covering a pre-existing disease. It is beneficial for you to search and compare various policies before zeroing in on the right one.

Life is a long journey with its own strange but enjoyable set of ups and downs. To enjoy each moment to its fullest, you must guard your family. Hence, health insurance carries immense importance in the world that we are living in today. It would help if you never waited for the pre-existing diseases to occur.

Instead, you should apply for health insurance early in your age so that you could avail the benefits of lesser premiums and more coverage. You should read the terms and conditions carefully before entering into a contract with the insurance company, mainly when it includes the pre-existing diseases of the insurer. So make sure you choose the best insurance plans to live life freely without any worries!

FAQs: Insurance Terms and Conditions and Pre-existing Illnesses

Do health insurance policies cover pre-existing conditions?

Not exactly! Hence, it is always suggested to buy a health insurance plan early in life. Not only does it ensure low premium but also get you better coverage as the chances of acquiring diseases are lower at a young age as compared to an ageing body. Lastly, if you opt for a group insurance policy, there is no waiting period for pre-existing conditions. Generally, corporates buy such insurance policies for their employees.

Is it worth buying a health insurance policy with a waiting period?

The rising costs of healthcare due to inflation have made health insurance a necessity in today's life. Also, with increased exposure to new diseases, Health Insurance has become all the more crucial. Therefore, there is no point in avoiding a health insurance policy, as every policy has a waiting period for pre-existing diseases. You should carefully select a suitable plan with the minimum waiting period. Lastly, if you buy the health insurance at some point, the waiting period will be only for pre-existing conditions.

Is the waiting period negotiable?

Health insurance companies could reduce the waiting period by charging a higher premium. Such decisions are based on individual firm policies. The waiting period is a safeguarding tool for the insurance companies as it restricts the access to the policy benefits as the policy holders have to wait for the time being before receiving insurance benefits. Average waiting period is 90 days. however, it may differ depending on the policy, diseases, coverage, premium etc.

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