The answer is a conditional ‘yes’. As per the Insurance Regulatory and Development Authority (Irda) order, insurance companies will have to provide health insurance to those suffering from pre-existing diseases after a waiting period, although, they are allowed to load additional premium to cover known ‘risks’.
What is a pre-existing disease? A pre-existing disease is defined as any known medical condition, ailment or injury or related condition(s) one has suffered within 48 months prior to the commencement of the health insurance policy. Pre-existing diseases are not just serious ailments, such as a heart condition or cancer, it can also be hypertension, asthma or diabetes or any previous injury.
Before taking an insurance cover, as a part of underwriting process, one has to make health declarations. It is important to make full and correct disclosures to an insurance company in the policy proposal form, because not doing so is considered a fraud. If at the time of a claim, the insurance company finds out that information was deliberately hidden, it can reject your claim and leave you in soup.
“It is always advisable that the policyholder undergoes a medical examination before taking a new health insurance plan. That way, the insurance company is aware of the medical condition of the policyholder beforehand and conflicts are reduced during the claims process. Also, depending on the policyholder’s medical records, an insurance company can either charge extra premium or impose permanent exclusions on certain diseases and ailments related to that disease,” said Antony Jacob, chief executive officer, Apollo Munich Health Insurance.
Insurance companies are wary of issuing health cover to those suffering from pre-existing diseases because the risks and likelihood of claims are higher. Insurance coverage of pre-existing diseases starts after the waiting period is over without a break in the policy. Waiting period is between two-four years, depending on the insurance company. It also varies with each ailment.
“Supposing, the policyholder has a pre-existing disease and takes a new policy, then he may file a claim for the pre-existing disease after the specified waiting period, even if he suffers from the same condition during the waiting period. However, the insured cannot file a claim for the disease during the waiting period,” said D Rama, assistant vice- president, product cell of Star Health and Allied Insurance.
If you are suffering from a pre-existing condition, check out the coverage and premium offered by specialised health insurance companies, such as Max Bupa Health Insurance, Star Health and Allied Insurance and Apollo Munich Health Insurance. They may offer you a better deal.
Disclosures: Most claim rejections by insurance companies are on account of pre-exiting diseases. While, insurance companies claim that the policyholder intentionally did not disclose the condition, it is possible that the policyholder was not aware of his condition.
Often, insurance agents dissuade customers from making a full disclosure, citing it as a reason for rejection of the policy. Setting aside such allurements, making disclosures would make filing your claims easier.
Coverage of pre-existing diseases varies from company to company. If you are looking at health cover for a pre-existing disease, do your homework. Get in touch with more than one insurance company and understand the terms and conditions. Some companies may give you partial cover for pre-existing diseases. It may be better to pay a little more and take full cover for pre-existing diseases. Reading the fineprint with emphasis on exclusions in your policy would be important. Even after enrolling yourself, if you are not happy with terms sand conditions, you can return the policy during the free-look period within 15 days and get a refund.
“Cataracts, hernia, piles, arthritis, sinusitis are generally excluded in the first year of the policy. Major life-threatening, pre-existing diseases are generally covered after four years. If the insurance company covers a pre-existing disease, then related ailments are also covered under the policy. Insurers generally decline 3-5 per cent of claims because the insured had either not declared the pre-existing diseases or supporting documents related to the ailments were not furnished,” said Sanjay Datta, head customer service, ICICI Lombard General Insurance.
Portability: To provide an option and flexibility to health insurance customers, beginning October 1, health insurance portability was introduced. Health insurance customers can switch between companies, along with all the benefits including the no-claim bonus option and most importantly, benefits, such as waiting period for pre-existing diseases. Policyholders will be allowed to carry forward the waiting period to the new insurance company. For example, the waiting period for a pre-existing disease does not change by switching to another company. If the waiting period is two years, it will remain the same irrespective of the company that covers the customer. Under portability, a customer needs to approach a new insurer within 45 days before his policy renewal date.
Refusal: Some insurance companies can refuse health cover to some pre-existing chronic ailments, citing those particular diseases as permanent exclusions. Each insurance company has a list of permanent exclusions. All insurance policies are issued at the discretion of the insurance company and as such, a company can decline your policy proposal on a case-by-case basis. Companies provide health cover based on their risk perception.
Group insurance schemes: Pre-existing diseases are generally covered in group insurance plans from the first year itself. If you have a group cover, mostly funded by employers, do find out about the inclusions and exclusions. In some group insurance policies, there is an option to co-pay for pre-existing covers, where in case of a claim, the cost will be shared by the insurance company and the insured.
Travel insurance: Pre-existing diseases are generally excluded from travel insurance policies. In case of hospitalisation during travel abroad, your insurance companies may reject claims. However, some companies such as Bajaj Allianz General Insurance have started covering pre-existing medical conditions also in travel insurance. If you are suffering from an ailment, it is better to check with the insurance company if it is covered, only then, you should buy a policy. ICICI Lombard General Insurance covers pre-existing diseases in life-threatening emergency situations.
Past treatment: A lot has changed with respect to treatment of pre-existing diseases by insurance companies. Earlier, due to ambiguity in the definition of pre existing diseases, companies rejected claims citing conditions.
From a customer’s perspective, however, the concern expressed is that some insurers are using the concept of “pre-existing condition” as an unfair means to deny or reduce coverage or payment. Such practices affect the credibility of a health insurance product and are one of the potential reasons for lack of acceptance/popularity of health insurance products in India.
To check malpractices and offer uniformity in health insurance policies, the General Insurance Council (GIC), a statutory body for all non-life insurers, has come out with a uniform definition on pre-existing diseases. Also, all policies issued from June 1, 2008, will cover pre-existing diseases from the fifth year of the policy. By the new standard definition, pre-existing exclusion means “the benefits (of health insurance) would not be available for any condition, ailment or injury or related conditions for which the insured had signs or symptoms, and/or was diagnosed and/or received medical advice/treatment, prior to inception of the first policy, until 48 consecutive months of coverage have elapsed, after the date of inception of the first policy”.