Pre-Existing Disease Cover in Health Insurance

Health insurance policies cover pre-existing diseases after the policyholder completes a waiting period of 2 to 4 years. The duration varies by plan, and some insurers offer options to reduce or waive the waiting period for quicker coverage.
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3 mins
09-May-2025

Given today's lifestyle in India, health insurance is a vital shield against unexpected medical costs. However, a crucial aspect often overlooked is the coverage for pre-existing diseases (PEDs). With conditions like asthma, high blood pressure, cholesterol issues, and diabetes becoming increasingly prevalent, having a health insurance policy that includes PED coverage is no longer a luxury but a necessity.

Typically, standard health insurance policies shy away from immediately covering PEDs due to the higher likelihood of claims related to these conditions. Nevertheless, the Indian health insurance landscape has adapted to address the evolving health needs of individuals. Now, numerous health insurance plans offer coverage even for applicants with pre-existing ailments, albeit often with specific terms and conditions.

Understanding the intricacies of pre-existing disease coverage in your health insurance policy is paramount. This includes comprehending the waiting periods, specific exclusions, and any additional premiums that might apply. Arming yourself with this knowledge ensures that your health insurance truly provides the financial security you need, especially when dealing with pre-existing health challenges. Let's delve deeper into the specifics of PED coverage in health insurance to empower you with the information needed to make informed decisions.

Pre Existing Disease Health Insurance : Overview

The Insurance Regulatory and Development Authority of India (IRDAI) defines pre-existing diseases (PED) as injuries, sickness, or any medical conditions diagnosed before buying a health insurance policy. Severe cases of injury are also considered PED in some policies. This definition excludes any diagnosis of illness within the first three months of purchasing a policy.

What is pre-existing disease in health insurance?

In health insurance, a pre-existing disease refers to any condition that a policyholder has been diagnosed with before purchasing the insurance. Generally, pre-existing diseases are covered after a waiting period specified by the health insurer. The waiting period may vary from six months to four years depending on the health insurance company. Pre-existing conditions are usually not covered in the initial waiting period; however, coverage starts once the waiting period is over.

The healthcare costs of a pre-existing disease are typically higher, which is why some health insurers have exclusions or higher premiums for pre-existing conditions. Therefore, it is important to disclose all pre-existing conditions when purchasing health insurance to avoid any future claim rejections or complications.

What is the waiting period for pre-existing diseases in health insurance?

After purchasing a health insurance policy, people cannot file claims immediately. For this, they have to wait for a certain period during which they cannot claim benefits. The initial waiting period is the first 30 days after purchasing the insurance. It is usually common across all health plans. However, this may vary from policy to policy.

Insurers can get reimbursements for the treatment of their pre-existing conditions after the completion of the waiting period. Typically, this duration can be anywhere between 30 days to 2 years. However, this may vary among different providers and depends on the applicant’s age, policy, type of illness and other such factors.

Why do health insurance companies restrict coverage for pre-existing conditions?

Health insurance companies often limit immediate coverage for health insurance pre existing conditions to manage risk and keep premiums affordable for all policyholders. Covering pre-existing illnesses from day one could lead to a surge in claims, potentially destabilizing the insurer's finances and driving up premium costs for everyone, including those without such conditions. This risk management strategy ensures the sustainability of the insurance pool.

Why is it important to disclose pre-existing diseases to your insurer?

Transparency is key when purchasing health insurance. Failing to disclose health insurance pre existing conditions can lead to serious repercussions later. If the insurer discovers an undisclosed pre-existing condition during a claim, they have the right to reject the claim and even cancel your policy. Honest disclosure ensures that your policy remains valid, even with a waiting period for PED coverage, ultimately providing the financial security you sought and preventing claim denials when you need them most.

List of pre-existing diseases covered in health insurance in India

Pre-existing diseases are health conditions that individuals have prior to purchasing a health insurance policy.

Here is a list of pre existing disease in health insurance that are commonly considered

  • High blood pressure
  • Asthma
  • Thyroid
  • Diabetes
  • COPD
  • Arthritis
  • idney disease

How do pre-existing diseases affect health insurance policies?

Pre-existing diseases wield significant influence over your health insurance journey, impacting both what's covered and how much it costs. Insurers meticulously assess the risk associated with these prior health conditions, often resulting in increased premiums to offset potential claims. You might also encounter extended waiting periods before coverage kicks in for treatments related to your pre-existing illness, or even specific exclusions where certain treatments won't be covered at all.

Furthermore, individuals applying for health insurance with pre-existing conditions may face more stringent underwriting processes. This could mean limitations on the overall benefits you're eligible for. In some cases, particularly with severe pre-existing conditions, certain insurers might unfortunately decline coverage altogether. Therefore, a thorough understanding of how pre-existing diseases in health insurance shape policy terms is absolutely vital for anyone seeking comprehensive protection without unexpected limitations or exorbitant costs. Knowing these implications empowers you to compare policies effectively and find one that best suits your health needs and budget.

Important things to know about health insurance for pre-existing medical conditions

Here are a few things that you must be aware of about buying a health insurance policy that covers pre-existing diseases:

● Disclose any pre-existing medical condition

It is mandatory to disclose any pre-existing diseases that you may have at the time of buying a health insurance policy. In case of non-disclosure, the insurance company can rightfully reject your claim. Providing false or misleading information or hiding health details from the insurer will complicate matters at the time of raising claim requests. Eventually, burdening you financially at the time of a medical emergency.

● Insurance terms and conditions may differ for pre-existing illnesses

Most insurance companies ask for medical check-ups to screen pre-existing health issues before offering a health insurance policy. Some insurers may also consider the applicant’s age and medical history before providing pre-existing disease coverage. The screening process, the list of pre-existing conditions, and the waiting period will differ for different insurance companies and health plans. Therefore, it is advisable to check the terms and conditions before opting for a health insurance policy.

● Pre-existing illness can affect insurance premiums 

It is important to keep in mind that insurers charge higher premiums to people with pre-existing illnesses. The insurance company will determine the exact premium amount based on an applicant's age, illness, etc. However, applicants must be transparent about disease history regardless of the premium charges.

● Not all health plans cover pre-existing diseases

There may be health plans that do not cover applicants against pre-existing ailments. Also, in many cases, insurers may not cover some pre-existing diseases in health insurance for the entire policy tenure. Therefore, you must check with the insurance company about this and select a policy accordingly.

Pro Tip

A comprehensive health plan not only covers hospitalization but also pre & post-treatment expenses, ensuring complete financial protection against rising medical costs.

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Tips to buy health insurance if you have a pre-existing disease

Here is a quick guide to help you find the right pre-existing disease cover health insurance policy that suits your requirement:

● Choose the right insurance provider

Although finding a policy that pre-existing diseases in health insurance may be slightly challenging, there are many insurance companies whose rules are not stringent. Some providers consider a person's entire medical history for providing insurance and deciding premium rates.

However, some insurance companies only consider the applicant's last two months’ medical history. Applicants can opt for comprehensive health insurance policies from such insurers.

● Compare policies

Applicants must always compare plans of different providers before getting insurance for pre-existing illnesses. Also, carefully check the terms and conditions to pick a plan that best suits in terms of their age, budget, and other unique needs.

Finding an insurer that offers health insurance policies covering pre-existing diseases can be slightly challenging. However, digital insurance providers have made buying health insurance policies online hassle-free. Bajaj Finance Insurance Mall hosts a range of comprehensive health insurance policies offered by leading insurers in India. You can visit the website to check the policies and buy as per your requirement.

Disclose your pre-existing condition honestly

Honesty is paramount when purchasing health insurance. Failing to disclose pre-existing conditions can lead to claim rejection and policy cancellation later on. While it might seem tempting to omit details, transparency builds trust with your insurer. Disclosing your complete medical history ensures that your policy accurately reflects your health status, paving the way for smoother claim settlements in the future, even if a waiting period applies to your specific condition.

Choose a plan with a shorter waiting period

For individuals with pre-existing conditions, the waiting period before coverage begins for those specific ailments is a critical factor. Compare different health insurance plans to identify those with the shortest waiting periods for pre-existing diseases. While a waiting period is often unavoidable, opting for a plan with a shorter duration ensures that you can access financial protection for your existing health concerns sooner rather than later, providing timely relief during medical needs.

Opt for a plan with minimal co-payment

A co-payment clause requires you to pay a certain percentage of the claim amount out of your pocket. When you have pre-existing conditions that may necessitate more frequent medical attention, choosing a plan with a minimal or no co-payment can significantly reduce your overall healthcare expenses. While premiums might be slightly higher for such plans, the reduced out-of-pocket expenses during claims related to your pre-existing conditions can offer substantial financial benefits in the long run.

Consider a high sum insured policy

Having a pre-existing condition doesn't negate the possibility of other medical emergencies arising. Opting for a health insurance policy with a high sum insured provides a larger financial cushion to cover not only potential treatments for your pre-existing condition (after the waiting period) but also any new illnesses or accidents that may occur. A higher sum insured offers greater peace of mind and comprehensive financial protection for all your healthcare needs.

Check for disease-specific health plans

Some insurance companies offer specialized health plans designed to cover specific pre-existing conditions like diabetes, cardiac ailments, or cancer. These disease-specific plans often come with tailored benefits and potentially shorter waiting periods for the targeted condition. If you have a specific pre-existing disease, exploring these specialized plans could provide more focused and relevant coverage compared to a generic health insurance policy.

Look for zero or reduced waiting period policies

While less common, some health insurance policies offer zero or significantly reduced waiting periods for pre-existing conditions, often with a higher premium. If you anticipate needing treatment for your pre-existing condition soon after purchasing the policy and are willing to pay a higher premium, exploring these options can provide immediate coverage and alleviate immediate financial concerns related to your health.

Check for lifetime renewability

When dealing with pre-existing conditions, ensuring continuous health insurance coverage is crucial. Opting for a policy with a lifetime renewability feature guarantees that you can continue to renew your policy year after year, regardless of any changes in your health status or the number of claims you've made. This provides long-term security and ensures that you remain protected even as your healthcare needs evolve over time.

Understand sub-limits and exclusions

Carefully review the policy document to understand any sub-limits on specific treatments or room rent, as well as any permanent exclusions for certain pre-existing conditions or related procedures. Knowing these limitations upfront helps you gauge the extent of coverage you can expect and avoid surprises during claim settlements. Understanding sub-limits and exclusions is vital for making an informed decision about whether a particular policy adequately meets your healthcare needs, especially with pre-existing conditions.

Consider a super top-up plan for extra coverage

Even with a base health insurance policy covering your pre-existing condition after the waiting period, a super top-up plan can provide an extra layer of financial protection. This plan kicks in once your base policy's sum insured is exhausted. For individuals with pre-existing conditions that might require extensive or long-term treatment, a super top-up offers an affordable way to enhance their overall coverage and safeguard against significant medical expenses.

How waiting periods work for pre-existing disease coverage

Waiting periods are a standard feature in insurance for pre existing medical conditions. Here's how they typically function:

  • Specific duration: A defined period (e.g., 2 to 4 years) must pass from the policy's commencement date before coverage begins for declared pre-existing illnesses.

  • Condition-specific: The waiting period usually applies specifically to the pre-existing conditions disclosed at the time of policy purchase.

  • Gradual coverage: Some policies might have a phased approach, where coverage for PEDs increases gradually over the waiting period.

  • No coverage during period: Generally, no claims related to the pre-existing condition are admissible during the waiting period.

Key do’s and don'ts when buying health insurance with a pre-existing condition

Do

Don't

Do disclose all pre existing illness insurance honestly.

Don't hide any pre-existing medical conditions.

Do compare plans for shorter waiting periods.

Don't assume all policies have the same waiting period.

Do understand policy exclusions and sub-limits.

Don't buy a policy without reading the fine print.

Do consider disease-specific plans if applicable.

Don't delay purchasing a policy if you need coverage.

 

Conclusion

Securing health insurance that includes coverage for pre-existing diseases might initially seem like a hurdle. However, the rise of digital insurance platforms has significantly streamlined the process of finding suitable policies online. For instance, the Bajaj Finance Insurance Mall serves as a convenient hub, showcasing a diverse array of comprehensive health insurance options from prominent insurers across India. By visiting their website, individuals can easily explore and compare various policies, empowering them to make an informed decision and purchase a plan that aligns perfectly with their specific healthcare needs and pre-existing conditions. This accessibility simplifies the journey towards obtaining crucial financial protection for everyone.

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Frequently asked questions

What is PED in health insurance?

PED stands for pre-existing disease. It refers to any medical condition that the policyholder has been diagnosed with before purchasing the health insurance policy.

How are pre-existing conditions determined?

Health insurance companies usually look into the medical history of the policyholder, such as past and current illnesses, hospitalisations, surgeries, medication usage, etc. The insurance company may also request medical reports or physical examinations to determine the pre-existing conditions.

What are some examples of pre-existing health conditions?

Some examples of pre-existing conditions are diabetes, hypertension, cancer, asthma, chronic obstructive pulmonary disease (COPD), heart disease, etc.

Does insurance cover pre-existing diseases?

Yes, most health insurance policies in India offer coverage for pre-existing diseases, but this coverage typically kicks in after a specified waiting period, which can range from one to four years depending on the insurer and the policy terms. While a waiting period is common, some policies may offer options to reduce this duration, and a few specialized plans might even provide immediate coverage for pre-existing conditions, often at a higher premium. Therefore, it's crucial to carefully review the policy details to understand the waiting period applicable to pre-existing illnesses.

How long is a condition considered pre-existing?

According to the Insurance Regulatory and Development Authority of India (IRDAI), a pre-existing disease is defined as any condition, 1 ailment, injury, or disease that was diagnosed or for which medical advice or treatment was received from a physician within the 36 months preceding the commencement date of the first policy issued by the insurer. While this 36-month window is a regulatory guideline, some insurance providers might also consider conditions existing beyond this period as pre-existing, so it's important to understand the specific definition used by your insurer.

What is the IRDA rule for pre-existing disease?

The IRDAI has established regulations to safeguard policyholders' interests regarding pre-existing diseases, stipulating that the maximum waiting period for these conditions is three years of continuous coverage. Importantly, insurers are prohibited from denying claims for any pre-existing condition after this mandatory waiting period has been served, provided there was no misrepresentation during the policy application. Full and honest disclosure of all pre-existing conditions during the application process remains a crucial obligation for policyholders to ensure claim admissibility.

Which diseases are not covered in health insurance?

While the specifics can vary between policies, there are common exclusions in health insurance in India, including cosmetic surgeries, infertility treatments, routine pregnancy care (unless specifically covered), most dental treatments, illnesses arising from substance abuse, self-inflicted injuries, sexually transmitted diseases, congenital external conditions, and often treatments for obesity and alternative therapies unless explicitly included. Additionally, some pre-existing conditions might be permanently excluded in certain policies, even after the waiting period, highlighting the importance of carefully reviewing the policy's list of exclusions.

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