Pre Existing Disease in Health
  • Impact of PEDs on your Health Insurance
  • Key Factors to Remember
  • Do's and Don'ts
what is pre existing disease in health insurance
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Pre Existing Disease in Health Insurance

The value of purchasing a comprehensive health insurance policy is underestimated by the people. They rely on the money and insurance provided by their employers. However, in today's world, the cost of medical expenses is rising, which is not economical for you. As a result, it is recommended that you and your loved ones should be covered with a suitable Health Insurance plan.

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Does Health Insurance cover Pre-Existing Diseases (PEDs) that you already have? Certainly not. That is why buying Health Insurance early in life is recommended. This not only ensures a lower premium but also ensures that you get better coverage because the risks of catching diseases are lower at a young age. This article will tell you about pre-existing diseases and health insurance.

What is a Pre-Existing Disease?

Pre-existing diseases are those medical conditions that an insured already has when they buy a new health insurance policy. The pre-existing disease is defined by IRDAI as a) any condition, ailment, injury, or disease diagnosed by a physician within 48 months of the policy's effective date or reinstatement, or b) any medical advice or treatment recommended by, or received from, a physician within 48 months of the policy's effective date or reinstatement.

List of 5 Plans For Pre-Existing Diseases in Health Insurance In 2024

  • HDFC Ergo Optima Restore Policy
  • HDFC Ergo Energy Diabetes Policy
  • Care Supreme Plan
  • Care Advantage Plan
  • Niva Bupa ReAssure 2.0

Get 4X coverage* without any extra cost under this comprehensive health plan for individuals and families.

Unique Features

  • No room rent capping
  • 100% SI restoration
  • E-opinion for 51 illnesses

Optima Secure Policy (Pros)

  • Secure Benefit
  • Plus Benefit
  • Automatic Restore Benefit
  • No room capping
  • Covid - 19 Cover

Optima Secure Policy (Cons)

  • Adventure Sports Injuries
  • Injuries Out of War
  • Death due to breach of law
  • Congenital Diseases
  • Alcoholism

Optima Secure Policy (Other Benefits)

  • Day Care Treatments
  • Road Ambulance Cover
  • Air Ambulance Cover
  • E-opinion
  • Organ Donor Cover

Optima Secure Policy (Eligibility Criteria)

  • Entry Age - 91 Days
  • Max Entry Age - No Age Limit
  • SI - 5 L to 2 Cr
  • Waiting Period - 30 Days

Designed especially for people with pre-existing diabetes or hypertension. Get coverage for diabetes and hypertension from Day 1 without any waiting period.

Unique Features

  • Stay fit & earn reward points
  • 100% SI restoration
  • Health coach & wellness programs

Energy Diabetes Policy (Pros)

  • In- Patient Hospitalization
  • No Waiting Period for Diabetes
  • Restore Benefit
  • Cumulative Bonus
  • Pre and Post Hospitalization

Energy Diabetes Policy (Cons)

  • 2 Year Waiting Period
  • Abuse of Intoxicant Not Covered
  • War Operations Injury
  • Sexsually Tranmitted Diseases
  • Pregnancy Not Covered

Energy Diabetes Policy (Other Benefits)

  • Monthly Newsletter
  • Organ Donor Benefit
  • Earn Rewards for Staying Healthy
  • 25% Discount On Renewal
  • 2 Variant Options(Silver,Gold)

Energy Diabetes Policy (Eligibility Criteria)

  • Entry Age - 18 Years
  • Max Entry Age - 65 Years
  • SI - 2 L to 50 L
  • Waiting Period - 2 Years

A unique healthcare plan offering extensive coverage to individuals and families under a single plan with affordable premiums.

Unique Features

  • Unlimited E-consultations
  • Unlimited Automatic Restoration
  • Avail Up to 30% Discounts

Care Supreme Plan (Pros)

  • Day Care Treatments
  • No Sub-Limits
  • Emergency Ambulance
  • No-Claim Bonus
  • Organ Donor Cover

Care Supreme Plan (Cons)

  • Change of Gender Treatments
  • Obesity Treatment Unavailable
  • Hazardous Activity Not Covered
  • HIV/AIDS not covered
  • Cosmetic Surgery unavailable

Care Supreme Plan (Other Benefits)

  • Unlimited Recharge
  • 30% Renewal Discount
  • Unlimited E - Consultation
  • Wellness Benefits
  • Nutrition and Fitness Coaching

Care Supreme Plan (Eligibility Criteria)

  • Entry Age - 90 Days
  • Max Entry Age - No age limit
  • SI - 5 L to 15 L
  • Waiting Period - 30 Days

Enjoy the advantage of 1 crore cover and multiple benefits at lower monthly premiums with this affordable individual & family floater plan.

Unique Benefits

  • No bonus claim up to 50%
  • Automatic SI recharge
  • Organ donor cover

Care Advantage (Pros)

  • Automatic Recharge
  • High SI
  • 50% No Claim Bonus
  • Ambulance Cover
  • Optional Cover Available

Care Advantage (Cons)

  • 20% Co-pay
  • Obesity Treatment Unavailable
  • Hazardous Activity Not Covered
  • HIV/AIDS not covered
  • Cosmetic Surgery unavailable

Care Advantage (Other Benefits)

  • 5 L Air Ambulance Cover
  • Reduction in PED Waiting period
  • Co-pay Waiver
  • Annual Health Check-up
  • Room rent modification

Care Advantage (Eligibility Criteria)

  • Entry Age - 91 Days
  • Max Entry Age - Lifelong
  • SI - 25 L to 6 Cr
  • Waiting Period - 30 Days

Niva Bupa Reassure 2.0 provides insurance holders with a high sum insured through their platinum, titanium, and bronze variants along with a multitude of other features.

Unique Features

  • Booster+ Benefit
  • Lock premiums at entry age
  • Health check-ups from day 1

Health ReAssure 2.0 Plan (Pros)

  • Personal accidents covered
  • Acute Care
  • Emergency Ambulance
  • Three Plan variants
  • Home Care Treatments

Health ReAssure 2.0 Plan (Cons)

  • No OPD Cover
  • No Maternity Cover
  • No Sleep Disorder Covered
  • Pre-Existing Diseases after 3 yrs.
  • Alcoholism not covered

Health ReAssure 2.0 Plan (Other Benefits)

  • Air Ambulance
  • Modern Treatments
  • Second Opinion
  • Booster Benefit
  • Shared Accommodation Benefit

Health ReAssure 2.0 Plan (Eligibility Criteria)

  • Entry Age - 18 Years
  • Max Entry Age - No Age Limit
  • SI - 5 L to 1 Cr
  • Waiting Period - 30 Days

Tips to Buy Health Insurance If You Have a Pre-existing Disease

Navigating the purchase of a health insurance plan for individuals with pre-existing conditions can be a tricky task, as each insurer has orchestrated clauses with many exclusions. Since every person's circumstances vary, it is essential to carefully assess your unique healthcare requirements and financial capabilities when choosing insurance coverage for pre-existing conditions. Here are a few tips to keep in mind

  • Research and compare plans
    Take the time to research and compare and look for plans that specifically cover your pre-existing condition and provide adequate coverage for your healthcare needs.
  • Pre-existing Disease Coverage
    Look for health insurance policies that offer coverage for these conditions after a waiting period of 48 months, as per the latest guidelines.
  • Full Disclosure
    Be transparent about your pre-existing health condition when purchasing the policy to avoid claim rejection in the future.
  • Long-Term Impact
    Insurance companies typically consider only health issues with long-term consequences as pre-existing diseases, not short-term ailments like flu or fever.
  • Lower Waiting Period
    Choose a health insurance plan with a shorter waiting period for pre-existing diseases, ensuring you can file claims sooner.
  • Co-payment Clause
    Avoid health plans that have a co-payment clause for these conditions, where you would be responsible for paying a percentage of the claim amount. Look for policies without this clause.
  • Network of healthcare providers
    Check if the health insurance plan has a network of healthcare providers that includes specialists or hospitals relevant to your pre-existing condition. Having access to preferred healthcare providers can be beneficial for managing your condition effectively.
  • Read customer reviews
    Look for reviews or testimonials from existing policyholders as their experiences can give you valuable insights into how well the insurance plan covers and supports individuals with similar health concerns.
  • Consider additional benefits
    Look for additional benefits as these may include coverage for specialized treatments, prescription medications, or preventive services that can support your overall health.
  • Review annual renewal options
    Check if the health insurance plan allows annual renewals without penalties or additional waiting periods for pre-existing conditions. This ensures that you can continue receiving coverage for your condition without any interruption.

List of Pre-Existing Disease In Health Insurance

Pre-existing Disease Description
Diabetes A chronic condition that affects blood sugar levels. Requires ongoing management and may involve medication, regular check-ups, and hospitalization.
Hypertension High blood pressure, which requires long-term monitoring and medication to control.
Asthma The serious respiratory condition causes breathing difficulties and wheezing. Often requires medications and occasional hospital visits.
Heart Diseases Conditions like coronary artery disease, heart attacks, and cardiac surgeries. May require specialized treatments and surgeries.
Thyroid Disorders Includes hypothyroidism and hyperthyroidism, which require regular medication and monitoring.
Arthritis Involves joint pain, stiffness, and inflammation, often requiring ongoing medication, physiotherapy, and joint replacement surgeries.
Cancer Life-threatening disease requiring comprehensive coverage for chemotherapy, radiation, surgeries, and other treatments.
Kidney Diseases Chronic kidney conditions such as renal failure and dialysis, require long-term treatment and possible kidney transplants.
Mental Health Conditions Includes depression, anxiety disorders, and bipolar disorder, emphasizing the importance of coverage for mental health treatments and therapies.

How Does Pre-existing Disease Impact Your Health Insurance Coverage?

Insurance is a concept in which an health insurance company provides financial support if something unfortunate happens to the policyholder as per the terms and conditions. If a person already has a pre-existing disease then the chances of raising a claim increase. As a result, Health Insurance Companies are reluctant to cover pre-existing conditions. Some Insurance Companies may cover them as per terms & conditions and charge a higher premium for them.

Why is it important to Declare Pre-existing disease?

You might be asking whether it's even necessary to disclose your pre-existing disease. However, in this circumstance, it's preferable to be completely transparent. Examine your medical records to be sure you've covered all of the illnesses and treatments you'll require. If you do not disclose your pre-existing disease to your Insurance Company and they discover it later, they will reject your claim. So, rather than not declaring your PED, it's preferable to wait for a time and get it covered.

Effects of a Pre-existing Disease on Your Health Insurance

The following is a list of the possible effects of having a pre-existing disease on your health insurance policy.

  • Premium LoadingThe premium will be on the higher side because the Insurance provider is taking the risk of covering a pre-existing condition. This premium loading is only applicable at the time of Insurance Purchase. It cannot be charged again if the policy is renewed without interruption.
  • Waiting PeriodThis is the time frame for which you must wait for your pre-existing diseases to be covered by your Insurance policy and It depends on the insurance provider who is providing the policy.
  • Premium Loading + Waiting PeriodIn some cases where you will charge a higher premium and have a long waiting period before covering an illness.
  • Medical Check-upIf you have a pre-existing disease, your Insurance company may require you to undergo a medical examination. The Insurance Premium will be based on the results of the tests. If the results are unfavorable, the insurance company may refuse to offer a policy.
  • Permanent ExclusionThe insurance provider may refuse to cover you If you have a pre-existing disease. You have to agree that the mentioned pre-existing disease in the policy agreement is a permanent exclusion in the policy. By doing this, you will be uninsured against your pre-existing diseases, & will be covered for other health scenarios if the policy's terms and conditions are met.
  • Policy DenialThe insurance company has the right to refuse to offer you the policy because of pre-existing diseases. They will deny your application to buy a Health Insurance Policy in such instances.

How to Buy Health Insurance for Parents Who Have a Pre-Existing Illness?

Purchasing health insurance for senior citizens with pre-existing conditions might be challenging. The following is a process to purchase Health Insurance for the elderly.

  • You can buy it via an online or offline medium.
  • The Insurance Company will ask you to undergo medical tests.
  • After the completion of the tests, the company's underwriting team will analyze the results and notify you of the status.
  • The Insurance Company may ask you for a higher premium or refuse to issue the policy.

Do's and Don'ts in case of Pre-existing Diseases

  • Do Share Information About Pre-existing Diseases With InsurerWhen communicating with the Insurance Company, be open and honest. If the Insurer asks you about your medical history, be honest.
  • Do Get A Check-upGetting a health check-up on your own is a smart idea. It will notify you if you have any existing diseases and will assist you in taking appropriate action.
  • Don't hide InformationBe open and honest with your insurer. Don't hide any information about your medical history.
  • Don't Fail To Compare Plans Before BuyingIf an Insurance Company refuses to sell you a policy or charges you a high premium to cover a pre-existing disease, you can do some online research and look into alternative choices.

Things You Should Know About Pre-existing Conditions

Here are a few key factors to remember about pre-existing conditions and Health Insurance.

  • Different Insurers Have Different PoliciesWhen it comes to pre-existing diseases not all companies follow the same set of rules. Some insurers may cover pre-existing diseases, while some may not. Some may have a shorter waiting period, while others may have a longer waiting period. Therefore, before buying the plan, read carefully the terms & conditions.
  • Every Doctor Visit is Not CountedCommon cold and cough will not count as a Pre-Existing diseases. It's not a problem to go to the doctor to get your headache treated. However, if you've had the headache for a year and are taking medicine, you may have pre-existing diseases.
  • Hiding A Pre-existing DiseaseTo avoid hassles during claim settlement, it's preferable, to be honest, and transparent with the insurance company about pre-existing conditions.
  • Non-Disclosure may result in Claim RejectionNon-disclosure of a pre-existing condition can result in policy cancellation or dishonoring of claims for such diseases. Claim rejection can be disturbing for you at the time of need. So, always disclose your PEDs to your Insurance provider and always be honest with them.

Pre Existing Disease in Health Insurance: FAQs

1. Is there any pre-existing disease health insurance in India?

There is no particular health insurance policy that covers pre-existing diseases in India. Each insurer covers certain policies mentioned in the policy document after a given period of time.

2. Where can I get the list of pre-existing diseases in health insurance?

Each insurer covers different pre-existing diseases which are mentioned at the time of commencement of the policy. To know about the disease you are looking forward to covering, you will have to look for a plan that covers it.

3. Can I reduce the waiting period for my pre-existing disease?

Generally, the waiting period is fixed and non-negotiable. However, you can contact your insurer and ask for the same. Some insurers can charge you higher premiums in exchange for a lesser waiting period.

4. I am already suffering from a disease. Can I buy a health plan?

Yes, you can buy a health plan if you have a pre-existing disease. The insurer will provide you with a waiting period if they cover the disease and then you can claim for insurance after completion of the waiting period.

5. What is the difference between pre-existing diseases and medical history?

Your medical history includes all of the health conditions you have suffered from whereas, pre-existing disease are the ones that you have since 48 months from the time of purchasing a health plan and have the chances of recurring in the future.

6. Is there a waiting period for a pre-existing disease in health insurance?

Yes, most health insurance plans have a waiting period for pre-existing diseases. This waiting period typically ranges from 2 to 4 years.

7. How can I buy pre-existing disease insurance?

Disclose your pre-existing health issues honestly at the time of purchasing the policy. Ensure you understand the coverage provided for pre-existing conditions and any waiting periods involved.

8. Can I get coverage for a pre-existing disease after a specific period?

Yes, as per the latest guidelines, health insurance companies can consider the medical history of the last 48 months to determine coverage for pre-existing diseases.

9. Should I hide my pre-existing illness while buying health insurance?

No, it is essential to disclose your pre-existing health issues accurately. Hiding it may lead to rejection in the future.

10. Are all doctor visits considered pre-existing diseases?

No, health insurance companies typically consider only health ailments that have long-term effects as pre-existing diseases. Short-term issues like flu or fever are usually not included.

11. What should I consider when choosing a health plan for pre-existing diseases?

Look for a health insurance policy with a lower pre-existing disease waiting period and without a co-payment clause for pre-existing conditions coverage.

12. How can I ensure a smooth claim process for a pre-existing disease in health insurance?

  • Maintain proper documentation of your medical history
  • Follow the prescribed treatments
  • Keep every treatment record
  • Network hospitals are best for treatments.
  • Read the terms and conditions of your health insurance policy to ensure a hassle-free claim process.

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Naval Goel

Reviewed By : Naval Goel

Naval Goel is the CEO & founder of Naval has an expertise in the insurance sector and has professional experience of more than a decade in the Industry and has worked in companies like AIG, New York doing valuation of insurance subsidiaries. He is also an Associate Member of the Indian Institute of Insurance, Pune. He has been authorized by IRDAI to act as a Principal Officer of Insurance Web Aggregator.