Health Insurance Policies - Fine Prints - Pre-existing Diseases

Pre-existing Diseases

The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any Insured person in connection with or in respect of:

All diseases/injuries which are pre-existing when the cover begins for the first time. For the purpose of applying this condition, the date of the start of the initial mediclaim policy taken from any of the initial mediclaim policies taken from any of the Indian Insurance Companies shall be taken, provided the renewals have been continuous and without any break.


This clause deals with the exclusions of ailments/diseases/injuries in the policy cover of an individual. This exclusion depends upon of such ailments/diseases/injuries or complications arising out of it, existing prior to the commencement (start) of the policy or an ailment that coincides with the beginning of the policy.

A pre-existing (or occurred) ailment/disease/injury having a definite co-relation with an existing diseaseis repudiated. Examples of pre-existing diseases are as follows: COPD (Chronic Obstructive Pulmonary Disease), Asthma, Hypothyroidism, Hyperthyroidism, Heart Ailments, Hypertension, Diabetes Mellitus, Thalassemia etc.

Most disputes occurring in the current scenario between the insurance companies and consumers are related to claims that arise mostly on account of pre-existing diseases. The debate pertaining to the duration of such pre-existing diseases could be some of the reasons following, as listed below:

• The disease may be in existence much before the commencement of the policy
• Disease/Ailment may be in existence but unknown to the policyholder and detected suddenly or during check-up. Examples include Hypothyroidism, hole in the heart, diabetes, hypertension, sickle cell anemia etc.
• Suppressed by the policyholder intentionally
• Policy taken by the patient soon after detecting the disease
• Discrepancy in dates of the ailment, either by the patient or Medical Practitioner or Hospital
• A very fresh policy

Requirement for Claim for Pre-existing Diseases - Based on fresh directives issued by IRDA, certain pre-existing diseases are being covered under the Insurance cover e.g. hypertension and diabetes are being covered only after the policyholder has been possessing a health insurance policy cover for a minimum of two or four or more years without a break in the policy cover. Also no hospitalization should be sought for the pre-existing ailment in those four years (since beginning of the policy cover) and no claim should have been made through any other Insurance Company. A continuous four claim-free years is a pre-requisite to be eligible for the benefit under the clause of pre-existing diseases. This directly implies that no claim should have been made by the claimant with the same or some other insurance company for that particular ailment or its associated complication for deriving the benefits.

The coverage of pre-existing diseases by various insurance companies varies to a great extent. So it is always recommended that the customer keeps himself updated with the latest health-insurance products and services available in the market. To have the pre-existing diseases covered for a particular individual, an additional amount that constitutes the premium needs to be paid for deriving the desired benefits from the policy cover.

If you have any disease you are advised to do some homework before purchasing the policy. You should be careful in your policy selection and have a discussion with your agent or someone senior in the company. It may be better to pay a little more to ensure that your disease is covered by the company.


A quick summary of the position taken by general insurance companies dated November 2009-10, is given below:

Reference

1. Best Health Insurance Policy in India - (https://www.apnapaisa.com/insurance/health-insurance-india/index.html)

Disclaimer: The contents of the article are in tune with the regulations in Insurance and TPAs (Third Party Administrators) since the past 2 years. The same rules are likely to prevail and be in force for the year 2009-10, unless changes/modifications/alterations/deletions/additions in existing regulations are made by the Insurance Companies, in tune with the guidelines issued by IRDA (Insurance Regulatory Development Authority). The author of this article does not take responsibility for changes made in the existing health insurance policy coverage which would occur with passage of time.

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