What Is Pre-Existing Disease (PED) In Health Insurance?

Due to changing lifestyles, poor food habits and stressful jobs, medical conditions such as diabetes, high blood pressure, cardiovascular diseases and obesity already exist till the time one reaches their late 50s or 60s. The latest report of National Family Health Survey of India has also highlighted the increased prevalence of non-communicable diseases such as hypertension, diabetes, thyroid in the younger population of India.

This is the testament that purchasing health insurance is not an option anymore; rather one must buy a comprehensive health insurance plan as soon as possible, which offers coverage against any ailments known as “pre-existing diseases”, diseases which have been already diagnosed, when you buy an insurance. 

What Do You Mean By Pre-existing Diseases?

Pre-existing diseases or PED is a kind of chronic or long-term medical condition which already exists at the time when one buys a health insurance.

The most common examples of pre-existing diseases are:

• High blood pressure
• Alzheimer’s Disease
• Cancer
• Diabetes
• Thyroid
• Asthma
• Obesity
• Sleep apnea
• Cardiovascular diseases
• Depression
• Bipolar Disease
• Chronic Obstructive Pulmonary Disease (COPD)

It is a very important factor in health insurance and coverage for such PEDs are not offered immediately as one buys a health insurance policy. The insured might have to wait for a certain amount of time period varying from one year to three to four years for the coverage of pre-existing diseases. This is what is called the “waiting period” for PEDs which varies from one insurer to another insurer.

For instance, you are in your mid 30s and a doctor suddenly diagnosed you with thyroid, and then after a year of diagnosis you buy yourself a health insurance policy. So, here thyroid will be termed as “pre-existing disease” in your health insurance.

Why to Declare Pre-Existing Diseases While Buying a Health Insurance Policy?

Whenever you are buying a health insurance plan for yourself, be very upfront with your insurance company about any medical condition which you are already suffering from. It is extremely important for you to disclose about your PEDs to your insurance company as it leads to smoother and faster claim settlement and lesser chance of claim rejections and even policy termination.

No matter, insurance companies might charge you extra in terms of premium costs, but declaring about your medical condition is a must, no matter how small or big the disease is. However, while buying a health insurance policy you must check, whether the policy covers PEDs or not, and if it covers, then what is the waiting period for the same.

So, remember, if you try to hide your pre-existing condition from your insurance company, and if by any chance they get to know later, then the consequences might be worse. So, it is better to wait for the PEDs to be covered after a while rather than not being covered at all, if you do not declare it.

Relevance of Waiting Period for Pre-Existing Diseases in Health Insurance

Earlier, it was not that easy for people diagnosed for pre-existing conditions to get proper coverage as there were higher chances of claim rejection, no coverage at all and increased waiting period of pre-existing ailments.

Then, the Insurance Regulatory and Developmental Authority of India (IRDAI) took a thoughtful decision to amend the definition of pre-existing diseases in 2020.

IRDAI defined pre-existing disease as 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 prior to the first policy issued by the insurer and renewed continuously thereafter.

As per the changed and updated definition, it means,

If an individual had a disease within 48 months or four years before buying a health insurance plan, it is to be treated as a pre-existing disease.

And, if an insured individual is diagnosed with any disease within the first three months of buying a health insurance policy, it will no longer be considered as a pre-existing disease. IRDAI has removed this paragraph clarifying the definition of pre-existing diseases, which benefits the customers.

This means, any illness contracted before buying the policy will be considered as pre-existing disease. And, if you have any illness that you were unaware of or was not diagnosed before my health insurance policy came into picture, would not be considered as PED.

This amendment has proved to be a game changer as it reduced the ambiguity around coverage for PEDs in health insurance and reduced the claim rejection among many policyholders. This change has also aided people to buy health insurance with a more positive attitude and less fear of policy termination.

With the new amendment, it is possible to get coverage for costly treatments related to PEDs at the usual premium rates but only after a certain waiting period, which varies from company to company and depends upon the severity of pre-existing condition.

Any hospitalization or medical bills related to your pre-existing disease will be covered by the insurance company only after the specified and predetermined waiting period. For instance, common pre-existing diseases like thyroid, hypertension and diabetes, the waiting period is generally between one to two years and for the severe one, it can last up to four years. 

And, if the policyholder files a claim before this waiting period,  then any claim made for such a medical condition is not accepted by the insurance company.

Disclaimer: Coverage of pre-existing conditions is subject to the term and conditions of the health insurance policy.

Factors to Consider While Buying a Health Insurance if You Have a Pre-Existing Disease

Is your disease a PED: First of all, one must identify that what you are suffering from is even considered as a pre-existing medical condition in health insurance or not. For instance, any kind of cough, cold, fever, or allergies are not pre-existing diseases. There is a particular list of PEDs with every insurance company, subject to an attached waiting period.  

For instance, for PEDs like thyroid the waiting period could be lesser than the waiting period of cancer or diabetes.

Pre-health screening: Go for a pre-medical check-up as defined in the terms and conditions of the policy. Health screening helps to give a clear picture of your well-being to the insurance provider and also reflects any pre-existing medical condition, if any.

Declare full information: Never hide anything from your insurance provider which may lead to claim rejection or policy termination. If you suffer from any pre-existing disease such as asthma or diabetes or any other medical condition, declare it at the time of buying the insurance policy.

Check the waiting period: Health insurance plans with PED coverage generally have a waiting period up to four years. The companies also offer an add-on for the reduction of the PED waiting period from four years to two or one year, which might be useful for you in future.  

Premium Amount: Check the premium amount as it might be little on the higher side, if the policy covers your pre-existing medical condition.

Check whether your plan covers PEDs or not: Remember that all plans do not cover pre-existing medical conditions, therefore before buying a plan you should check the inclusions and exclusions of policy.

What You Must Do While Buying a Pre-Existing Health Insurance Policy? 

If you are already diagnosed with PED and wish to buy a health insurance policy, then you need to be extra careful as the terms and conditions of each insurer varies when it comes to covering any of the pre-existing medical conditions. If you are suffering from an ongoing medical condition which requires costly treatment or frequent hospitalization or clinic visits, select that kind of health insurance plan which covers it all at less terms and conditions.  

It is important that you do your research by comparing several plans online on the basis of waiting period, list of PEDs covered and most importantly, premium quotes. Pick up an insurance plan which suits your needs, health conditions and pocket completely.

You must be sure that your chosen health insurance policy would be able to take care of the treatment costs related to the pre-existing medical condition in every best possible way, after the completion of the waiting period as specified in the policy.  

Best Health Insurance Policies with Less Waiting Periods for PEDs

Forbes Advisor India has collated a list of health insurance plans which offers reduced waiting time for the pre-existing diseases to be covered. 

Frequently Asked Questions (FAQs)