Pre-existing conditions in health insurance

Any medical problem, illness or injury that you have before buying health insurance is called a pre-existing condition. Many diseases like diabetes, COPD, cancer and sleep apnea can fall under this category. Most serious and long-lasting diseases are kept in this category.

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The direct answer to this simple question is yes. However, different diseases are covered after different time intervals in different health insurance companies, i.e. the waiting period varies. If you claim for any pre-existing condition during the waiting period, the insurance company will reject your claim. However, many companies provide coverage for certain pre-existing conditions from day one.

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• You must have continuous insurance cover for at least 24 months for the treatment of pre-existing diseases. That is, after 24 months from the date of issue of myUpchar Insurance Plus policy, you can claim your pre-existing condition. However, this rule does not apply to a claim arising out of an accident. (Read more: Personal Accident Insurance)
• If you have increased the amount of your sum insured, then you will have to wait for 24 months after increasing it to claim the increased amount.
• Even after the waiting period of 24 months, only those medical conditions are covered, which are accepted by the insurance company while giving you the policy. Read your policy bond carefully for more details on this.
• While some insurance companies allow you to claim for several pre-existing conditions after a waiting period of 24 months, some other companies have a waiting period of 48 months. It’s best to read your policy bond carefully and note such details.
• If you are not happy with your insurance company, then our advice would be to port your policy to another company once the waiting period for the pre-existing condition is over. If you do not wait for this, your waiting period can be restarted again. However, many insurance companies also reduce the waiting period by charging an additional premium.
• Many insurance companies come out with plans with an option of co-payment for pre-existing conditions. On taking such a policy, you will have to pay some part of the medical bill on your own, as per the conditions of co-payment, during the treatment and the remaining part will be covered by the insurance company.

You can take advantage of health insurance despite the pre-existing condition but it all depends on how well you research the health policy you choose to buy.

Any illness or injury that has been diagnosed or treated before purchasing the policy is considered a pre-existing condition. The related terms and conditions are changed by IRDA from time to time. According to the circular in February 2020, if a disease is diagnosed within three months of taking the policy, it will not be considered a pre-existing disease, whereas, in the 2019 circular, such a disease was included in the category of pre-existing diseases.

In myUpchar Bima Plus policy, a disease is treated as a pre-existing condition if it is diagnosed within 48 months prior to taking the policy or a situation in which a doctor prescribes a treatment within the 48 months before taking the policy or restarting the lapsed policy. Apart from this, if a disease has symptoms and it is diagnosed within three months of taking the policy or if any treatment is needed, then it is considered a pre-existing condition.

Health insurance companies consider many conditions and diseases to be pre-existing conditions, and especially if they are chronic conditions, meaning that they last for a long time. If a woman is already pregnant before taking the policy, it is also considered to be a pre-existing condition. Some of the following diseases are placed in the list of pre-existing diseases:

• Treatments associated with arthritis (if non-infectious), osteoarthritis and osteoporosis, gout, rheumatoid arthritis, spinal disorders (not caused by an accident), joint replacement surgery (not caused by an accident), arthroscopic knee surgery, ACL reconstruction or meniscal and ligament repair.
• Surgical treatment of benign ear, nose and throat, adenoidectomy, mastoidectomy, tonsillectomy and tympanoplasty associated disorders and surgeries, nasal septum deviation, sinusitis and other disorders.
• Benign prostatic hypertrophy
• Cataracts
• Dilation and curettage
• Fissure (anal fistula), piles, pilonidal sinus, gastric and duodenal ulcer
• Surgery involving the genitourinary system (unless fatal)
• All types of hernias and hydroceles
• Hysterectomy for menorrhagia, fibromyoma or lowering of the uterus (unless fatal)
• Internal tumours, skin tumours, cysts, nodules, polyps including lumps in the breast (any type) unless malignant
• Kidney stone, ureteric stone, lithotripsy, gall bladder stone
• Myomectomy for fibroids
• Varicose veins and varicose ulcers
• Genetic disorders
• Parkinson's, Alzheimer's disease and dementia
• Epilepsy
• Diabetes
• High blood pressure
• Thyroid
• Lupus
• COPD
• Cancer
• Atherosclerosis
• Depression

However, some less serious conditions such as acne, asthma, anxiety disorders and sleep apnea can also be placed in this category.

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People suffering from pre-existing conditions often need to go through various procedures. In such cases, your insurance company can deny the claim, cancel the coverage and even cancel your health insurance. Now, this may make it seem like health insurance cannot be taken with pre-existing conditions, but it isn't so and you can get a health policy. Following are some important things you need to know if you have pre-existing diseases and wish to buy health insurance:

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• Check out other company's plan: Buying health insurance with a pre-existing condition can be difficult, but all health insurance companies are different. There are some companies that ask for your complete medical history related to pre-existing conditions, while some companies offer you a health insurance policy after looking at the medical history of only the last few years.
• Never hide pre-existing conditions: You may wonder if it would be alright to take health insurance without disclosing a pre-existing condition, but this is totally wrong. If a claim related to that disease is filed in the future, then the insurance company can refuse to pay the claim on the basis of medical history.
• Seeing a doctor does not mean medical history: Health insurance companies consider only those diagnoses or treatments as a pre-existing condition, which have a long-term effect. If you often have the flu, cough, cold and fever, there is no need to panic - they do not last long and are not included in pre-existing conditions.

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Do you want to take a health insurance plan but fear that you will not get health insurance due to a pre-existing disease? As we have mentioned above, pre-existing conditions can be covered by health insurance. Yes, it is true that in some cases, you may be denied the policy or you may be charged an increased premium. If you are suffering from a disease that is not treatable or is very expensive to treat, then you will be prone to making frequent claims. In such a situation, the company refuses to provide insurance or you are charged a hefty premium. Not only this but the condition of a waiting period of 24 to 48 months may also be applied.

If a woman is pregnant at the time of taking the policy, that also classifies as a pre-existing condition. Many other serious and long-lasting diseases, like cancer and HIV that are already present before the policyholder has taken the policy, are not covered by the insurance companies. However, some companies offer insurance claims for the same by charging an additional premium and after the waiting period of up to 48 months.

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Whenever you are buying a health insurance plan, you should always keep certain things in mind:

• When filling the form to take the policy, do not lie at all about your medical history in it.
• If you have a pre-existing condition, then inform the company about it accurately.
• If you do not specify the pre-existing condition, the insurance company may reject your claim in the future.
• If the insurance company comes to know that you have taken the policy by lying, then it can refuse to renew the policy.
• If you have a pre-existing condition, the insurance company can cover your illness after a certain waiting period and/or by charging an additional premium.
• Whenever you buy health insurance for yourself, you must compare different plans by many companies. You should not only look at the premium but also compare other important aspects like coverage, network hospitals, claim ratio and waiting period. Apart from this, always read the terms and conditions of your policy.

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