What Are IRDAI Regulations for Pre-Existing Diseases in Health Insurance?

The importance of health insurance cannot be stressed enough, especially since the global pandemic has changed the normal ways of life. Now, health has become the prime concern. Moreover, health ailments can strike at most inopportune times. It can lead to a debt-trap if not planned well in advance. To have you mental as well as financial security, health insurance becomes a crucial part of your financial portfolio. But often a question pops up when buying one – what about already existing medical conditions? Are they covered by my health insurance plan?

A short answer to the above question is yes, the regulator, Insurance and Regulatory and Development Authority of India (IRDAI), has issues guidelines about pre-existing health ailments. Before you understand these guidelines, let us understand –

What is meant by pre-existing diseases?

Pre-existing ailments are medical conditions that the policyholder is suffering at the time if purchase of insurance cover. These diseases that already exist at the time of buying a health insurance policy either are included or specifically excluded from your policy coverage depending on the terms and conditions specified by your insurer.

Are premiums impacted due to pre-existing ailments?

Yes, any already existing health condition does impact the premium since it increases the risk for the insurance company. Further, these pre-existing ailments bring about a condition of waiting period wherein the insurance company includes that specific ailment in its scope after a specified duration. Until this specified duration, the insurer does not offer any coverage for the ailments that were existing at the time of purchase. In some cases, the insurance companies provide instant coverage too. But this comes with an additional loading to your premium. Even if it increases the premium, it offers the advantage of a health insurance cover to support the treatment costs. Remember that loading is only possible in case of pre-existing ailments. If any disease occurs after the policy is purchased and renewed without any break, it cannot be loaded for additional premium. Some instance of critical ailments come with premium loading along with a waiting period. At these times, opting for a dedicated critical illness insurance can be beneficial.

The regulators guidelines on pre-existing diseases

The earlier definition amended by IRDAI in September 2019 included a clause which stated ailments that are diagnosed within three months of purchasing the policy as pre-existing diseases. This amendment created ambiguity and let to disputes between the insurance companies and policyholders. As of February 2020, this definition of pre-existing diseases stands modified to delete that clause and now any condition that is diagnosed or treatment that is recommended 48 months prior to purchase of policy is classified as pre-existing ailment.

Whether you are buying an individual cover or health insurance plans for family, make sure to take a note of the clause specifying pre-existing ailments. Not only it will make the right selection, but also purchase a policy that fits your budget. To summarise, a pre-existing condition is the one that already existed at the time of buying the health insurance policy. The terms for coverage of pre-existing conditions vary among insurers, it is recommended you declare them to avoid any rejection of your claim application.

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