Pre-Existing Disease Cover In Health Insurance

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Pre-Existing Disease Cover In Health Insurance

In today’s world, there are so many people who suffer from lifestyle diseases like thyroid, obesity, diabetes, hypertension and more. This is largely due to the increased stressors around us and indulging in substances like smoking, drugs and alcohol abuse that aggravate these diseases further.

Such factors can lead to chronic diseases like heart conditions, cancer, and asthma, posing a threat not just to our emotional stability but also to our financial well-being. There are so many expenses incurred for patients living with ailments that are terminal or life-long. These include the cost of medicines, regular tests and diagnostics, consultations etc.

Pre-Existing Disease Cover Overview

It was not easy to claim health insurance for a person with a pre-existing disease (PED). There were certain terms and conditions in the old PED clause that restricted patients who had a pre-existing disease from availing their health insurance. However, The Insurance Regulatory and Development Authority of India (IRDAI) has revised the pre-existing disease list as well as the pre-existing disease health insurance cover.

Role of IRDAI

IRDAI is responsible for the regulation and implementation of insurance policies of the country. It makes sure that everything ultimately benefits the policyholders. It is an autonomous body that protects the interests of the policyholders. It has made certain amendments to the pre-existing disease clause that has positively impacted all insurance consumers.

Old Definition of Pre-Existing Diseases

According to the earlier definition, PED’s were classified as chronic diseases like high blood pressure, cancer, diabetes etc., that an individual possesses at the time of buying health insurance or whose symptoms develop three months after the date of issue. These diseases are thus, not covered under the insurance plan, and the policyholder cannot claim the insurance till the specified waiting period lapses.

For instance, if you are diagnosed with a disease as mentioned in the pre-existing disease list before buying the insurance, you won’t receive any coverage for medical expenses linked to that disease. Moreover, three months after buying the policy, if there are any imminent signs or symptoms that indicate the development of a fatal illness, that would also be considered a pre-existing disease.

In addition, if a disease needs to be treated as specified by a medical professional within 48 months from the date of insurance issued, that will also be categorized as a pre-existing disease. This has seriously impacted the rate of insurance buying in India.

As per the old clause, the pre-existing disease list in health insurance allowed the insurers to reject or terminate claim requests altogether if the policyholder had any of the diseases mentioned in that particular list. Insurance providers are generally apprehensive of giving a healthcare plan to people with chronic ailments as they have to undergo many procedures. This rejection of claims also led to people hiding their existing illness and not disclosing crucial information about their health when buying the health insurance initially. You should refrain from doing so, as at the time of a health emergency, the insurer can reject your claim on the grounds of misrepresentation.

New Definition of Pre-Existing Diseases

Now, the new definition has proved to be a game-changer. As per the circular from IRDAI on 10th February 2020, the pre-existing disease clause states that if an individual develops symptoms of an ailment or is diagnosed with a disease mentioned in the pre-existing disease list by a medical professional in the first three months of buying the policy, it is not considered as a pre-existing disease. This move has changed the functionality of the pre-existing disease cover in health insurance completely. As a result, the rejection rate has been significantly brought down, which has aided people with a more positive attitude towards buying insurance.

According to the new terms, only those diseases that are prevalent and have been diagnosed before buying the insurance are considered PEDs. Therefore, if you have an illness that you were unaware of or was not diagnosed before the insurance came into effect, it would not be considered under PED.

This new amendment helps the policyholders in such a way that they won’t have to wait for a couple of years to claim their insurance for pre-existing disease. The PED insurance would cover the costly treatments of such diseases.

Waiting Period

The basic understanding of the waiting period is that you cannot claim health insurance immediately after buying a healthcare policy. The policyholder must wait for a set time frame that ranges from 30 days to 4 years. The first 30 days after buying a healthcare plan is the initial waiting period, constant for all types of health insurance policies. You cannot avail an insurance claim for any treatment in this initial waiting period. Waiting period for PED can range from two to four years as per the offer by different insurance providers.

Some Facts About Pre-Existing Disease Cover

1.Several insurance companies have different criteria for PED Cover. For example, they might or might now include an existing ailment under your health insurance plan before issuing the policy. Others might offer a reduced waiting period.

2.Insurance portability should be considered when looking for PED cover. It allows you to transfer if you wish to change to a different insurance provider for reasons like better PED coverage claim, reduced waiting period, PED Cover for whole family etc.

3.Hiding health-related information is never an option as it can land you into trouble in times of need. In fact, clearly mentioning all medical problems when buying health insurance will allow you to customize and choose a better plan that covers your expenses to the maximum. Therefore, before buying a policy, it is important to disclose the disease(s) you suffer from, and convey that information first-hand to your insurance provider as there are different plans that you can choose from to best suit your needs.

4.In case of an accident, the waiting period does not apply, and the insurance can be claimed in such a case.

TATA AIG’s MediCare Insurance Plan enables you to have comprehensive coverage that covers pre-existing diseases and specified diseases (tumours, PCOD, osteoporosis etc.). In addition, our insurance portability feature allows easy transfer so that you can make an informed choice. For more information, please read our policy wordings thoroughly.

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