Health

Updates for Pre-Existing Ailments in Health Insurance as per IRDAI Regulations

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Health insurance is no luxury in today’s day and age, but in fact, a necessity that cannot be overlooked. With soaring treatment costs due to rising medical inflation, it is difficult to avail standardised treatment for ailments using your hard-earned savings. To add to it, all your financial plans are disturbed when such medical exigency takes place and you need to pay from your own pocket.

Health Insurance

Thus, to safeguard your finances and alleviate any financial stress due to medical treatments, a health insurance policy comes to the rescue. The earlier you start, the more advantages you get. But what if you have missed the early train? Can you not apply for one?

It isn’t the case. You can purchase a health insurance policy irrespective of their age. But when buying one, one critical factor that needs attention is coverage for pre-existing diseases.

What are pre-existing diseases and how do insurance companies deal with them?

Pre-existing diseases are those medical conditions that the policyholder is already suffering at the time of policy purchase. So, if you are diagnosed with an ailment at the time of policy purchase, it is termed as a pre-existing disease.

Different insurance companies deal differently with such pre-existing ailments. Some levy an additional premium, whereas some others mandate a waiting period to include them as part of the coverage; some may even implement both, a premium increase as well as a waiting duration. Some insurers also cover pre-existing diseases in their critical illness insurance plans.

Additional levy of premium increases the cost of insurance coverage, while waiting duration requires you to wait for a specified period till the ailment is a part of your policy’s scope. Even if the premium is increased, ensuring coverage for such pre-existing ailment is essential as it has a higher probability of occurrence in the near future despite seeking medication. * Standard T&C Apply

The regulator, IRDAI’s take on pre-existing ailments

In September of 2019, IRDAI announced modification of the pre-existing ailment clause. This modification led to rejection of applications buy the insurance companies. However, in February of 2020, this amendment was soon deleted resolving the ambiguity caused by it. Here’s a comparative table showcasing the old and the new definition.

Earlier definitionAmended definition
Pre-existing disease means any condition, ailment, injury or diseasePre-existing disease means any condition, ailment, injury or disease
  1. that is/are diagnosed by a physician within 48 months prior to the effective date of the policy issued by the insurer

or

  1. that is/are diagnosed by a physician within 48 months prior to the effective date of the policy issued by the insurer or its reinstatement

or

  1. for which medical advice or treatment was recommended by, or received from, a physician within 48 months prior to the effective date of the policy or its reinstatement.
  1. for which medical advice or treatment was recommended by, or received from, a physician within 48 months prior to the effective date of the policy issued by the insurer or its reinstatement
  1. a condition for which any symptoms and or signs if presented and have resulted within three months of the issuance of the policy in a diagnostic illness or medical condition.
(deleted)

(Source: IRDAI)

You can visit the official website of IRDAI for further details.

So, to summarise, a pre-existing disease in means any condition that is already in existence at the time of availing health insurance coverage. It is generally excluded from coverage for a waiting period which can be a maximum of 4 years. Once the waiting period is completed, all pre-existing ailments are automatically covered subject to the terms of the policy. * Standard T&C Apply

Please note that insurance is the subject matter of solicitation. For more details on benefits, exclusions, limitations, terms and conditions, please read sales brochure/policy wording carefully before concluding a sale.

Carol P. Middleton
Student. Alcohol ninja. Entrepreneur. Professional travel enthusiast. Zombie fan. Practiced in the art of donating rocking horses for the underprivileged. Crossed the country researching hula hoops in Deltona, FL. Won several awards for supervising the production of etch-a-sketches in Nigeria. Uniquely-equipped for investing in bathtub gin in the financial sector. Spent a year building g.i. joes worldwide. Earned praise for deploying childrens books in Africa.