Pre-existing Diseases covered in Health Insurance

What is meant by Pre-Existing disease in Health Insurance?

Pre-Existing Disease

Pre-Existing Disease means any condition, ailment, injury or disease:

a) That is/are diagnosed by a physician within 48 months prior to the effective date of the policy issued by the insurer, or

 b) 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

Pre-Existing Diseases (PEDs) and its complications play a major role in Health Insurance. Offering Health Insurance coverage to people with PEDs is subject to the underwriting norms of the insurer. If the insurer accepts the declared Pre-Existing Diseases and issues a policy (mentioning the PED and its complications are covered with a specific Waiting Period), then, during the Waiting Period, your insurer will not be able to cover your medical expenses for the specified Pre-Existing disease and its complications. 

Usually, the maximum Waiting Period for PEDs and their complications is four years. But it varies from one insurer to another.

 PED, a crucial factor in Underwriting

Underwriting is the process of selection of risk classified as standard or normal, substandard and decline. Underwriting is an important part of Health Insurance. Underwriters assess the probabilities, possibilities and determine under what terms to issue coverage.

Underwriting of any policy is based on the health status, health history and other risk factors. The evaluation is also based on the severity of the disease – from acute to chronic condition. Acute conditions occur suddenly with a rapid onset and can be cured, while chronic conditions persist over a long period and may not be curable.

Pre-Existing Diseases play an important role in the underwriting process. For your insurer, if your PED is part of permanent Exclusions, the insurer will not accept your policy proposal in the first place. Some insurers may issue you a policy with a higher Premium, while some may also fix a Waiting Period during which the treatment for PED will not be covered in Health Insurance. 

Criteria for issuing a Health Insurance policy

Insurers have certain criteria while issuing a Health Insurance policy for you and your family, such as:

1. Whom do you want to cover? (Individual/Floater)

2. Where do you reside?

3. Have you been consulting a medical practitioner on any previous ailment or injury, apart from hospitalisation due to delivery or accident?

Factors considered during Underwriting

Risk – Probability and possibility of financial loss, where the insurer agrees to compensate the loss to the insured.

Based on the assessment of the risk, the underwriter will decide on the acceptance of the proposal. 

Tips for choosing the best Health Insurance Policy for Pre-Existing Diseases 

Health Insurance is meant for medical emergencies. The approach toward Pre-Existing Diseases and their complications differs in every Insurance Company. 

Let us consider the following criteria while finding a Health Insurance cover for the Pre-Existing disease:

1. Pre-insurance Medical Test/Screening

Certain insurers will not require a pre-Insurance medical screening, while some make it mandatory. The pre-Insurance medical check-up/screening is the decision of the Insurance Company. So, choose the suitable and convenient one for you. 

2. Make sure to reveal Pre-Existing disease (if any)

During the claim process, if any Pre-Existing disease and its complications are evaluated, and the insurer realises that, Pre-Existing disease is non-disclosed, the chances of the policy getting canceled are higher. Your claim may not be approved, leading to unnecessary hassle. Hence, it is mandatory to disclose all the health issues, especially information on your PED and its complications, during the proposal stage.

3. Disclosures and material facts in Health Insurance

Material facts influence the risk levels assessed by an underwriter relevant to the Insurance Company. Facts regarding the age, height, weight, build nature of the occupation, personal habits like smoking/drinking, medical history, surgeries, earlier Insurances, etc., are material facts and need to be disclosed by the proposer. These material facts enable the insurer to assess the degree of risk involved.

Any misrepresentations/non-disclosure of the material facts affects the Insurance cover. Material facts in Insurance help to determine the coverage amount and the Premium charged by the insurer. If the information disclosed by the proposer is found not to be true, the claim can be rejected and can lead to the Insurance contract being null and void.

4.  Check for the Premiums

Look for Premiums before choosing the Health Insurance policies covering the PEDs and their complications. 

Some insurers offer a customer-centric approach with the following options:

• Waiver of waiting periods for PED and its complications usually observed in Corporate Policies.
• Reduction in PED and its complications Waiting Periods on payment of additional Premium.
• PED and its complications with the minimum Waiting Period, ranging from 6 months to 4 years.

Know your Exclusions

There are two types of Exclusions in Health Insurance – Time-bound Exclusions and Permanent Exclusions.

Time-bound Exclusions include Pre-Existing Diseases or specific diseases with a Waiting Period of 2-4 years. The Waiting Periods are usually product/plan-specific. 

However, Permanent Exclusions are the ailments/conditions that are never covered in Health Insurance. These ailments may include Sarcoidosis, Malignant Neoplasms, Epilepsy, Heart Ailment, Congenital heart disease and valvular heart disease, Cerebrovascular disease (Stroke), Inflammatory Bowel Diseases, Chronic Liver diseases, Pancreatic diseases, Chronic Kidney disease, Hepatitis B, Alzheimer’s Disease, Demyelinating disease, HIV and AIDS, loss of Hearing, Papulo squamous disorder of the skin, Avascular necrosis (osteonecrosis), self-intentional injuries, war or combat injuries, hazardous sports injuries and much more.

Star Health Insurance offers some unique Health Insurance plans tailored to cover Pre-Existing Diseases and their complications. Let us have a look at them.

Young Star Insurance Policy

 Young Star Insurance Policy is available on both an Individual and Family Floater basis. It covers Pre-Existing Diseases and their complications after 12 months of continuous cover. You can consider opting for the Gold or Silver plan based on your requirements.

Star Comprehensive Insurance Policy 

Star Comprehensive Insurance Policy offers overall coverage for all planned and unplanned medical treatments and expenses. This policy covers Pre-Existing Diseases and their complications after 36 months from the date of activation of the policy. Yet, there is also an optional cover called Buyback PED. In this option, the Waiting Period gets reduced from 36 to 12 months on paying an additional Premium. 

Senior Citizens Red Carpet Health Insurance Policy

If you need a health plan covering your parent’s pre-existing ailment and its complications, consider choosing the Senior Citizens Red Carpet Health Insurance Policy

In this policy, Pre-existing Diseases and their complications are covered after 12 months.

Let us also know about Star Health Insurance’s specific Pre-existing disease cover,

Diabetes Safe (Plan A) Insurance Policy 

Star’s Diabetes Safe Insurance Policy covers both Type I and Type II Diabetes, regular hospitalisation and outpatient expenses. People having Diabetes can always opt for this policy to avoid huge medical bills.

The policy comes with two types of plans – Plan A and Plan B, both having unique features. For Pre-existing Diseases and their complications related to Diabetes, there is no Waiting Period under Plan A and a 12-month Waiting Period under Plan B. People with Diabetes complications can opt for Plan A, but the coverage is approved only after undergoing a pre-Insurance medical screening. Whereas, in Plan B, a pre-Insurance medical screening is not mandatory.

This policy also covers non-Diabetic people (when you opt for a floater plan with minimum one person Diabetic). The initial Waiting Period of this policy is 30 days, except for accidents. Coverage for PEDs is with 48-months Waiting Period and for specific diseases after a 24-month Waiting Period.

Star Cancer Care Platinum Insurance Policy

Star Cancer Care Platinum Insurance Policy coverage for persons diagnosed with Cancer. It also provides indemnity coverage for medical expenses incurred for Cancer and Non-cancer ailments. This plan is available to persons who are diagnosed with Cancer in the age group from 5 months to 65 years. You can opt for a maximum Sum Insured option of Rs. 10 lakhs. The plan does not require a pre-Insurance medical screening, irrespective of age.

Summing Up

Health Insurance is the most important financial tool you need to consider purchasing for your secured future. If you have a pre-existing illness, it is always wise to opt for the right Health Insurance policy catering to your needs, thereby avoiding financial worries during medical treatment.