New Delhi: Buying health insurance is an important financial decision, but policyholders need to understand the terms and conditions before purchasing a plan. Among the most important factors are pre-existing diseases and waiting periods, which can directly affect when and how certain medical expenses are covered.
According to the Insurance Regulatory and Development Authority of India (IRDAI), buyers should disclose all existing health conditions while applying for a policy. Concealing medical information can lead to disputes at the time of a claim and may result in claim rejection or cancellation of the policy.
What is a pre-existing disease?
A pre-existing disease generally refers to a medical condition, illness, injury or disease that was diagnosed, or for which medical advice or treatment was received or recommended, within the period specified under the applicable health-insurance rules and policy terms before the policy began. Under the current IRDAI health-insurance framework, the relevant look-back period is up to 36 months.
Examples can include conditions such as diabetes, hypertension or other illnesses for which a person was already receiving medical advice or treatment before purchasing insurance.
Why does the waiting period matter?
A waiting period is the time during which certain diseases or treatments are not covered by the policy. IRDAI states that the waiting period for pre-existing diseases can be up to 36 months under the current framework. Specific treatments or diseases may also have their own waiting periods, subject to the policy terms.
This means buyers should not assume that every medical condition will be covered immediately after purchasing a policy.
Read the policy before buying
IRDAI advises consumers to carefully check important policy conditions, including:
Waiting period for pre-existing diseases
Waiting periods for specific diseases and treatments
Exclusions
Room-rent and ICU limits
Co-payment requirements
Deductibles and sub-limits
List of eligible hospitals and cashless facilities
The insurer is also required to provide a Customer Information Sheet (CIS) explaining key features, exclusions, waiting periods and other important policy terms.
Disclosure of medical history is important
Experts and regulators advise buyers to provide accurate information about their medical history when applying for health insurance. Providing incomplete or incorrect information can create problems later, particularly when a major hospitalization leads to a claim.
Policyholders should also maintain continuous renewal of their health insurance, as continuity can be important for waiting-period benefits and other protections. IRDAI says that portability and migration rules can allow certain accumulated credits, including waiting-period credits, to transfer subject to applicable conditions.
Consumers should compare policies carefully
Health insurance plans can differ significantly in their coverage, exclusions, waiting periods and cost-sharing requirements. Therefore, buyers should compare the policy wording and Customer Information Sheet rather than choosing a plan solely on the basis of premium.
Understanding pre-existing disease rules and waiting periods before purchasing a policy can help consumers avoid unexpected surprises when they need to make a medical claim.
