Find the best health insurance with pre-existing disease coverage - OneAssure
Learn about pre-existing diseases in insurance. Discover tips and recommendations for choosing the right health insurance for pre existing disease.
10 min read
August 30, 2024
Simmran Sharma
We are seeing a rising prevalence of lifestyle and premature diseases in India. This significantly impacts the common public, health industry and insurance industry. While the public grapples with medical bills and distress, insurers are facing increased claims and higher medical costs, leading to rising premiums. This evolving landscape requires insurers to maintain higher financial reserves and invest in health promotion to ensure long-term stability and effective coverage.
However, the first step towards facing these challenges is consumer awareness. With this article let us explore what qualifies as a pre-existing disease and the nuances of waiting periods. We’ll later delve into the impact of recent regulatory changes by IRDAI as well.
What is pre-existing disease in insurance
A pre-existing ailment is a condition that a policyholder has before acquiring a health insurance policy. According to IRDAI guidelines, a health condition diagnosed up to 36 months before purchasing the policy is considered a pre-existing disease.
a) Does health insurance cover pre-existing diseases?
Yes, it is possible to find health insurance that covers pre-existing conditions. Securing the right health insurance for pre-existing diseases ensures that you receive the following essential benefits in a timely manner:
> Financial protection: Reduced financial strain and effective management of medical expenses, contributing to long-term financial stability.
> Access to comprehensive care: Access to a broader range of medical treatments and procedures, like diagnostic tests and advanced therapies, which might be unaffordable without insurance.
> Coverage for associated health complications: PEDs can result in complications or related health issues. Health insurance can help cover the costs associated with these complications.
> Preventive and routine care: Insurance can cover routine visits, helping to maintain health and prevent the escalation of the condition.
> Access to a network of providers: Network hospitals have agreements with insurance providers to offer cashless treatment to policyholders. These healthcare facilities can offer better rates and services than out-of-network care.
Here are some common types of pre-existing diseases that might be relevant in health insurance:
Pre-existing diseases in health insurance | |
| Cancer | Breast cancer, prostate cancer, lung cancer, and colon cancer. |
| Blood disorders | Hemophilia, anemia, and thalassemia. |
| Musculoskeletal disorders | Arthritis (rheumatoid arthritis, osteoarthritis), osteoporosis, and lupus. |
| Endocrine disorders | Hypothyroidism, hyperthyroidism, and adrenal gland disorders. |
| Diabetes | Type 1 and Type 2 diabetes. |
| Cardiovascular disease | Hypertension, heart disease, stroke, angina, and coronary artery disease. |
| Respiratory conditions | Asthma, chronic obstructive pulmonary disease (COPD), and chronic bronchitis. |
| Renal conditions | Chronic kidney disease, kidney stones, and nephritis. |
| Gastrointestinal issues | Crohn’s disease, ulcerative colitis, and chronic gastritis. |
| Neurological disorders | Epilepsy, Parkinson’s disease, and multiple sclerosis. |
| Mental health disorders | Depression, anxiety disorders, and bipolar disorder. |
| Reproductive health issues | Polycystic ovary syndrome (PCOS), endometriosis, and fibroids. |
| Autoimmune diseases | Systemic lupus erythematosus, rheumatoid arthritis, and multiple sclerosis. |
b) What is ‘waiting period’?
Individuals seeking health insurance for pre-existing diseases (PED) should be aware that coverage for these conditions is not available from day one. Coverage for pre-existing diseases can only be obtained once the waiting period has elapsed.
i) Meaning
Waiting period is the time frame that must elapse before certain benefits or coverage become active. During this period, the policyholder cannot claim benefits for specific conditions or treatments. This period varies by policy and typically applies to pre-existing conditions, maternity benefits, and some types of coverage.
Waiting periods are put in place to avoid immediate claims and enable the insurance companies to manage risks. Typically, any medical insurance plan will have a waiting period of around 36 months for these diseases. Therefore, when choosing a health insurance plan, it’s important to select one with the shortest possible waiting period.
ii) Types
In insurance, different types of waiting periods apply to various aspects of coverage. Here are the key types:
> Initial waiting period: Active immediately after purchase of policy. During this time, no claims are accepted, except for those resulting from accidents. Initial waiting period typically ranges from 30 to 90 days.
> Pre-existing condition waiting period: Expenses for hospitalization and treatment related to pre-existing conditions can only be claimed once the waiting period of 2-4 years has been fulfilled.
> Maternity waiting period: Maternity-related claims, such as childbirth or related treatments, are covered only after completion of this period to manage their high costs. It usually ranges from 9 to 36 months.
> Disease-specific waiting period: A waiting period for coverage of certain diseases and procedures, such as ENT disorders, joint replacement and cataract surgery, typically lasts at least two years.
Accidental injuries are often covered immediately or within a few days of buying health insurance.
iii) Factors that influence waiting period in insurance policy
Waiting periods in insurance vary depending on following factors:
> Age of policyholder: Older individuals may face longer waiting periods for certain types of coverage. This is due to the increased risk associated with aging, which insurers account for when setting waiting periods.
> Location of purchase: Waiting periods fluctuate with regional variations in healthcare costs, medical infrastructure, and insurance regulations.
> Type of policy: Policies may differ based on their coverage options, benefits, and inclusions. Comprehensive plans with extensive coverage might offer shorter waiting periods compared to basic plans.
> Underwriting policies: Policies for risk management can vary among different insurance companies. Some insurers may offer more flexible terms or shorter waiting periods for similar types of coverage.
Higher premiums are usually charged for immediate coverage or lower waiting periods.
Are pre-existing diseases same as lifestyle diseases
No, pre-existing diseases and lifestyle diseases are related but distinct concepts. Let us understand how.
a) One is product of the other
While pre-existing diseases can sometimes be influenced by lifestyle factors, not all pre-existing diseases are lifestyle-related. Some are genetic or caused due to other non-lifestyle factors. In broader terms:
i) Pre-existing diseases refer to any medical conditions or illnesses that a person has before a certain point in time, such as before they start a new job or undergo surgery. These can include a range of conditions from genetic disorders to chronic illnesses that were diagnosed prior to that specific reference point.
ii) Lifestyle diseases, on the other hand, are illnesses primarily caused by unhealthy lifestyle choices and behaviors. These can include diseases like heart disease, type 2 diabetes, and certain cancers. They often result from factors such as poor diet, lack of physical activity, smoking, and excessive alcohol consumption.
b) Modern day lifestyle factors that cause pre-existing diseases
Our lifestyle is shaped by a myriad of factors. Some such factors are born from our sole autonomous decisions, while others are the product of either modern day culture or deep-rooted traditional and societal norms. Pre-existing conditions, prevalent in today's society, stem from some such factors driving us down the path of an unhealthy way of life.
| Sedentary state | People spend a significant amount of time sitting due to jobs, commuting, and sometimes for recreational activities too. Lack of physical activity contributes to conditions like obesity, type 2 diabetes, hypertension and sometimes depression. |
| Stress | Chronic stress from work, academics, personal life, and societal pressures can lead to various health problems, including heart disease, high blood pressure, and mental health disorders. |
| Unhealthy diet | Diets high in processed foods, sugars, unhealthy fats, and low in fruits, vegetables, and whole grains contribute to obesity, heart disease, diabetes, and other health issues. |
| Excessive alcohol consumption | Drinking alcohol in large amounts or on a regular basis can lead to liver disease, cardiovascular problems, and an increased risk of certain cancers |
| Smoking | Tobacco use is a major risk factor for many chronic diseases, including lung cancer, heart disease, stroke, and respiratory conditions. |
| Environmental factors | Urbanization and environmental pollution can contribute to health issues. Poor air quality and exposure to environmental toxins can exacerbate respiratory and cardiovascular conditions. |
| Socioeconomic factors | Economic instability, lack of access to healthy food options, healthcare, and recreational facilities can impact an individual’s ability to maintain a healthy lifestyle. |
| Cultural and social norms | Societal norms and cultural practices can influence lifestyle choices, such as dietary habits and attitudes towards physical activity, which can impact health. |
Efforts to mitigate these factors often require a multi-faceted approach promoting healthy lifestyles, enhancing healthcare access, implementing preventive measures, and improving public health education across various demographics.
c) How it fosters burden on healthcare
The rising prevalence of PEDs are leading to a fall in quality healthcare received by individuals since they lead to:
> Increased medical costs
> Loss of work productivity leading to more financial strain
> Pressure on healthcare infrastructure, including hospitals, clinics, and specialized care units.
> Reduced quality of life
d) Resulting impact
> High early mortality rate
> Economic disruption
> Emotional distress
> Social disruption
Addressing these issues requires a comprehensive approach, including lifestyle modification programs, improved access to healthcare, financial aid, public health campaigns, and policies aimed at reducing risk factors. Health insurance can be an important part of the solution. Let us see how.
Health insurance to the rescue!
Diseases cause physical, emotional and financial distress. Health insurance is one of many ways to keep your head above water. It aids:
> Disease prevention: through regular screening, check-ups, vaccination that also reduces risk of severe complications.
> Treatment: provides access to specialists, medication, hospital stays, surgeries and more ensuring patients receive the care they need.
> Finances: With coverage for ongoing care, individuals can manage their finances better and avoid unexpected large medical bills that could otherwise impact their financial stability.
> Awareness: The health insurance industry focuses on consumer awareness and behavioral incentives urging policyholders to adopt healthier lifestyles by offering reduced premiums and rewards.
How to pick out best health insurance for PED
> Pick the policy with minimum waiting period: Policies with a shorter waiting period allow you to claim coverage sooner. Look for policies with the shortest waiting period for pre-existing conditions, ideally 1 to 2 years.
> Keep sum insured amount high: The sum insured is the maximum amount the insurer will pay for your medical expenses. A higher sum insured offers better financial protection. Consider future medical needs and inflation when selecting the amount, ensuring it covers potential treatment costs adequately.
> Forego pre-policy medical test if possible: Pre-policy medical tests are health screenings required before the policy is issued. Avoiding these tests can simplify the application process and avoid potential rejection or higher premiums based on your health status.
> Understand premium-loading to find an affordable plan: Affordable premiums are essential to maintaining long-term coverage. Premium loading refers to an increase in premium due to health risks or pre-existing conditions. Look for plans with a good coverage-to-premium ratio. Some insurers may have higher premiums for pre-existing conditions, so seek policies with reasonable premium loading.
Additional tips
> With health insurance portability, you don’t have to wait out the pre-existing condition waiting period again.
> You can shorten the pre-existing condition waiting period by opting for a reduced wait period add-on available in our various plans.
> Choose a health plan that excludes a co-payment clause.
Compare so you don’t compromise
Don’t fail to compare plans before making a purchase. If an insurance company declines coverage or imposes high charges for a pre-existing condition, you can explore other options by researching online to find better alternatives. Or skip the hassle and let experts weigh things for you. Oneassure will find you your perfect policy by analyzing:
> Coverage variability
> Waiting period
> Premium costs
> Sum insured limits
> Exclusions & limitations
> Additional benefits
All this from the best health products offered by top companies. Not only this, we will stay by your side throughout the process of authorization, claims and reimbursement. Providing you assistance every step of the way.
Aftermath of hiding PEDs while securing policy
When buying a health insurance policy, it is essential to disclose pre-existing diseases (PEDs) accurately. Inability to do so could lead to:
> Policy nullification: If you fail to disclose pre-existing conditions and they are later discovered, your insurance policy might be declared null and void. This means you could lose all coverage benefits, leaving you without insurance when you need it most.
> Claim rejection and loss of premium: It could lead to rejection of claims related to undisclosed pre-existing conditions leaving you responsible for medical expenses. Additionally, any premiums paid up to that point could be lost if the policy is invalidated due to non-disclosure.
> Penalties for incomplete/ false information: Insurers might impose financial penalties or legal actions for misrepresentation/ fraud. This can result in fines or other legal consequences.
All being said, if a health condition was truly unknown and not diagnosed before the policy came into effect, it is not considered a pre-existing disease. Full disclosure and understanding your insurer's specific terms are crucial to ensure proper coverage and avoid potential issues.
Recommended health plans for PEDs
Take a look at what these plans have to offer:
| Diabetes/ hypertension/ cholesterol coverage | Insulin-diabetes coverage | Coverage for cardiac health |
Latest adjustments by IRDAI
The Insurance Regulatory and Development Authority of India (IRDAI) is the regulatory body for the insurance sector in India. It oversees insurance companies and protects policyholder’s interests. In 2024, IRDAI announced the following for health insurance coverage of pre-existing diseases in a notification. Following came into effect on April 1, 2024:
Subject | Changes made | Old ceiling | Current ceiling |
| Max waiting period | The definition of a pre-existing disease (PED) has been updated to reduce the maximum waiting period. Note that this revised definition is not standard across all policies including overseas travel policies. | 48 months (4 years) | 36 months (3 years) |
| Moratorium period | The specific duration during which certain conditions or claims are not covered by the policy was also shortened. After this period ends (including portability and migration), the insurer cannot deny any claims covered by the policy, except in cases of fraud. | 96 months (8 years) | 60 months (5 years) |
| Specified disease waiting period | Waiting period during which coverage for specified diseases and treatments is not provided has also been shortened. Note that this excludes accidents, which remains 2 years in most policies, far less than any other waiting period. | 48 months (4 years) | 36 months (3 years) |
These reductions will benefit both existing and new policyholders. Some other important modifications made clear in the notification were:
> Prohibition of health insurance companies from denying policies to individuals with severe pre-existing conditions. Such as heart disease, cancer, renal failure, and AIDS. This mandate aims to create a more inclusive medical insurance environment and broaden coverage across India.
> Removal of entry age limit reference for insurers to offer health insurance plans in India mandating insurers to to offer health insurance plans to individuals of all ages. This guideline is particularly advantageous for senior citizens, giving them the flexibility to purchase a comprehensive health insurance policy at any time.
> Removal of sub-limits on AYUSH treatments, allowing policyholders to claim costs for ayurveda, yoga and more similar treatments up to the full sum insured limit.
Bottomline
The interplay between increasing prevalence of premature lifestyle diseases and the health insurance industry creates a dynamic environment. For this insurers continuously adapt their products, pricing strategies, and risk management approaches. Understanding and navigating these elements all while keeping up to date with recent changes can be like trying to keep several balls in the air. With proper guidance and comparison of various plans, policyholders can achieve better coverage and avoid potential pitfalls. To receive fine-tuned recommendations that meet your checklist for an ideal health insurance policy, book a free consultation on +91 6364334343 or click here.