Do Health Insurance Plans Cover Congenital Diseases in India?

Congenital Diseases and Health Insurance in India: What You Need to Know  

Adopting a nutritious diet, sufficient sleep and regular exercise can help prevent diseases and physical frailties. Nonetheless, individuals with Congenital Diseases seem to acquire these ailments even when maintaining healthy practices. The expenses for treating these conditions can be challenging. Hence, it is natural to question whether health insurance in India covers Congenital Diseases. 

Congenital diseases  

Congenital diseases, also known as congenital anomalies or genetic disorders, are conditions that are present in individuals from birth. These diseases can be either structural or functional congenital disabilities that develop during the baby’s time in the womb. 

Genetic mutations, environmental factors, maternal age, maternal nutritional status, infections, or socioeconomic factors may cause them. It is possible to detect these anomalies before birth, at birth, or during the early years of infancy. 

According to a joint report by the World Health Organization (WHO) and the Ministry of Development (MOD) in 2016, approximately 1.7 million people in India suffer from congenital diseases, which accounts for 6-7% of the total population. While internal congenital diseases may not be visible, external congenital anomalies can be easily identified. However, babies with congenital disorders may experience health issues or disabilities throughout their lives. 

Some of the common types of congenital diseases include:

•  Congenital heart disease 
• Edward’s syndrome 
• Cerebral palsy 
• Phenylketonuria 
• Club foot 
• Thalassaemia 
• Down syndrome 
• Cystic fibrosis 
• Sickle cell disorder 
• Cleft lip and cleft palate 
• Congenital hypothyroidism 
• Spina bifida 
• Fragile X syndrome 

Prevalence of Congenital Diseases in India

According to various studies, congenital diseases make up a significant part of public health problems in India. Many of the congenital disorders that exist in the country originate from a range of genetic factors and not-so-good maternal care. Such medical conditions require extended intervention, so health insurance coverage is crucial for affected families.

The coverage of congenital diseases under health insurance plans in India is significantly different between providers and policies. Generally, most standard health insurance policies do not cover congenital conditions primarily because they have been considered pre-existing conditions. However, some insurers now realize the need to cover congenital diseases due to changing healthcare requirements.

What is the scope of health insurance coverage for congenital conditions in India?

 
Yes, all standard health insurance plans in India offer coverage for congenital diseases by the 2019 guidelines of IRDAI (Insurance Regulatory & Development Authority of India). 

These plans encompass the expenses related to diagnosing and treating congenital diseases, including in-patient hospitalisation, daycare procedures, surgeries, pre-hospitalisation, post-hospitalisation, and more. The coverage amount can vary from Rs 50,000 to Rs 6 crore. 

However, the extent of coverage and the amount are contingent upon the specific health insurance plan you purchased. 

However, it is essential to acknowledge that health insurance plans in India do not cover all congenital diseases. According to the guidelines set by IRDAI, only internal congenital diseases are eligible for coverage under standard health insurance plans. In the case of an individual suffering from an external congenital disease, the insurance company will not be liable for covering the expenses related to the treatment.

Waiting period for congenital diseases 

Health insurance providers typically offer coverage for Congenital Diseases. Still, it’s important to note that you may not be eligible to file a claim for such a condition during the waiting period. 

Most health insurance plans have a waiting period of two years for coverage of congenital conditions. This means a claim can only be submitted for a congenital condition once two policy cycles have been completed. However, this condition applies only if the diagnosis is made after purchasing the health insurance policy. 

On the other hand, if the diagnosis was made before purchasing the policy, the disease may be considered a pre-existing condition. In this case, you may need to fulfil a waiting period of up to four policy cycles before being eligible for coverage. Carefully review your health insurance plan’s policy terms and conditions to obtain more information about the waiting period clause.

Challenges to Getting Coverage

Lack of Awareness

Most people seeking health insurance do not know how policies treat such conditions. This creates an element of surprise and, worse still, financial shocks when a medical need arises.

Limitations in Policies

While some health insurance packages may include treatment for congenital diseases, there may be limits on the type of treatment to be covered, the levels or the maximum amount for any condition.

Specialized Care Needed

Such conditions usually require expensive special medical treatment, such as surgeries and ongoing treatments; hence, families need to have comprehensive health insurance coverage in case of such conditions.

Tips to Prevent Congenital Diseases 

Here is a compilation of recommendations to help prevent Congenital Diseases for expectant mothers. If you are concerned about your baby’s well-being, these tips can provide reassurance and guidance in minimising the chances of your child being born with a congenital disorder. 

• Avoid taking medications that may result in congenital disabilities.  
• Ensure you receive the appropriate vaccinations, particularly for rubella.  
• Consume nourishing food abundant in vitamins and minerals.
•   Sustain an optimal body weight to promote good health. 
• Avoid visiting areas experiencing outbreaks of infections like the Zika virus.  
• Incorporate folic acid supplements into your diet during your reproductive years and in the initial stage of pregnancy.  
• Refrain from consuming alcohol, drugs, and cigarettes while pregnant. 
• Minimise exposure to dangerous substances such as pesticides and lead. Manage your diabetes effectively, if applicable. 

Summary 

Congenital disorders have long-lasting consequences. Your child will not only have to cope with numerous health issues throughout their lifetime, but the costs of treatment will also deplete your savings rapidly. Fortunately, health insurance plans in India offer coverage for internal congenital diseases. Nevertheless, it is advisable to adhere to the suggestions above and make every effort to prevent your child from acquiring a congenital disorder.

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