Understanding Pre-Existing Disease In Health Insurance

Let us imagine you apply for a health insurance policy at a top health insurance company in India for your elderly parents who have a medical condition like diabetes.

So what happens next?

The insurer either approves your application with higher premiums than usual or rejects your application.

Now both of these happen because your parents have a pre-existing disease.

So let us answer questions like, what is a pre-existing disease? How do we purchase a health insurance policy with a pre-existing condition? And how does this affect group health insurance and individual health insurance plans?

What is a pre-existing disease?

According to the IRDAI, pre-existing disease or a pre-existing condition refers to any ailment, illness, disease or injury which is diagnosed by a physician within 2 years (48 months) before purchasing your health insurance policy. 

In simple words, 48 months prior to the effective date of the policy issued by the insurer, if you suffer from any disease or ailment that requires medical treatment then, it is considered as a pre-existing disease. 

Common PEDs include:

• Diabetes
• Asthma
• Thyroid
• Hypertension
• Cancer
• Cardiac issues

But why does an insurer reject or increase the premium for the health insurance policy for people with a pre-existing condition? 

Well, the answer is simple because when suffering from a pre-existing condition like thyroid, cancer, asthma, cardiac problems, or any other named ailments you are more likely to file a health insurance claim. It means your health insurer is at a greater financial risk. At the end of the day, even the health insurance companies wish to run a profitable business.

Why Are Pre-existing Conditions a Big Deal for Insurers?

People with Pre-existing Conditions are more likely to make claims, increasing the insurer’s financial liability. That’s why they may charge:

• Higher premiums
• Increase waiting periods
• Or reject high-risk cases

If you hide a pre-existing condition and the insurer finds out, they can deny the claim or cancel the policy.

So, how do we purchase a health insurance policy with a pre-existing disease?

Well there are two ways to purchase a health insurance policy with a pre-existing disease.

Buy and Wait- Firstly, you can purchase a health insurance policy and wait. Yes, it's that simple. People with a pre-existing period can also get coverage for their ailments after a certain period commonly known as a pre-existing disease waiting period. However, it depends on the type of health insurance policy you opt for and the terms and conditions of your policy.

Even pregnancy is considered as a pre-existing condition hence, your maternity insurance has a certain waiting period.

Buy and Pay Higher Premiums- Secondly, you can purchase health insurance and pay higher premiums to waive some of your pre-existing disease waiting period.

Pre-existing disease waiting period 

The pre-existing disease waiting period varies from one insurer to another. It can be mostly a period between 1 to 4 years in most cases. Also, it largely depends on factors like your age, your condition, the type of health insurance policy, etc. 

So, if you file for a health insurance claim for such specific diseases in between this period, your claim may get rejected.

‍Pointers to keep in mind before the policy purchase for people with pre-existing disease

Terms and conditions vary across different insurance companies

Always read the terms and conditions of your health insurance policy. Because the waiting period for the pre-existing disease varies across different insurance companies. Some health insurance companies also offer a benefit known as “waiver of a pre-existing condition”. With this, you can cover your pre-existing illness and its treatment costs.

Not all conditions are pre-existing diseases

Not all conditions you suffer are pre-existing diseases. In simple words, not all doctor visits count. If you suffer from a cold, cough, fever, etc then do not panic. Insurance companies consider only those diseases which have an impact over the long run. 

Never hide your pre-existing disease

It is always a bad idea to hide your pre-existing disease. There are high chances that your insurer may reject your claim or decide to not cover you at all. However, the insurer cannot deny you a health insurance policy on the grounds of pre-existing illness.

Start early

It is always a good idea to purchase your health insurance policy in the early years when you are healthy. Such that the insurer starts covering you from day 1 for any medical condition. 

Reducing the waiting period

Some insurers will ask you to pay a higher premium and in turn, they waive or reduce the pre-existing disease waiting period. 

Understand co-payment clauses
Some health insurance plans with PED coverage come with a co-payment clause, meaning you’ll need to bear a fixed percentage of the total bill (like 10–30%). Always check this before purchase.

Check insurer's claim settlement ratio
Opt for an insurer with a high claim settlement ratio, this increases the chances of your claim being approved, even if it involves a PED.

Look for disease-specific plans
For chronic PEDs like diabetes or cancer, some insurers offer specialized plans with better coverage, benefits, and reduced waiting periods.

Disclose lifestyle habits
Habits like smoking or drinking may impact how your PED is evaluated. Full transparency ensures your policy remains valid during claims.

Network Hospitals for Chronic Condition Management

Not all network hospitals may offer specialized care for chronic illnesses. While choosing a policy:

• Check for diabetes or cardiac care units
• Ensure availability of day-care services
• Look for tie-ups with labs for regular diagnostics

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Pre-existing disease: Group health insurance vs Individual health insurance

So all the above-mentioned effects of pre-existing disease on health insurance are applicable for individual health insurance policies and other family floater policies only.

While purchasing your individual health insurance plan or family floater plan, you have to undergo a mandatory health check-up. It screens you for any medical condition or any disease you suffer. But this is not the case with a group health insurance policy plan that your organization or your employer provide.

Yes, you heard it right! A bit of a shocker isn’t it?

When your organization provides you with a group health insurance policy, all your pre-existing diseases are covered from day 1 with 0 waiting period. 

Well, how does this happen?

In a group health insurance policy the risk factor is spread across your employees and not on a single employee. Furthermore, the premiums paid are much lesser than an individual insurance policy.

Pretty cool, isn’t it?

To sum it up

You can always purchase a health insurance policy with a pre-existing disease. You can either purchase health insurance plans specifically for pre-existing diseases like cancer or diabetes and get coverage for your conditions. Or else, you can purchase a health insurance plan with a pre-existing diseases waiting period. However, these may vary from one insurer to another depending upon their terms and conditions.

Offer employee healthcare benefits with Pazcare

At Pazcare we provide group health insurance policies for your employees at the best prices. You can customize the plan according to the needs of your workforce. The pre-existing diseases are covered from day 1 with 0 waiting periods. The employees can also opt for a maternity cover along with their group plan. Check out our group health insurance guide to know more about it. Not only that you can also cover your workforce with group personal accident cover and group term insurance to protect their families financially against any unforeseen circumstances. The best part is administering all of these benefits at a single place using the Pazcare dashboard.

Talk to our team to get more insights about the plan and its benefits. Get a competitive quote for your team and get started.

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