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- Introduction
- What are Pre Existing Diseases & What is a Pre Existing Disease Waiting period?
- Understanding the phrase - “To the best of your knowledge”
- What can happen if you do not make accurate declarations?
Introduction
All health insurance plans come with certain waiting periods - a time period during which some specified conditions are not covered by the policy. In fact, for the first one month, the insurance plan will not pay for any condition or treatment - with the only exception of accidental hospitalizations. This first month is the initial waiting period in health insurance. There are other types of waiting periods imposed on specific conditions such as maternity, pre existing conditions, certain specific conditions mentioned in the policy as well.
Waiting periods are integral to health insurance. They basically ensure that people do not buy policies after discovering a condition or getting a diagnosis. Through waiting periods, the insurer reduces frauds and remains viable - and has enough money in their kitty to pay out genuine claims.
For instance, take the case of Mr. Kapoor. He recently met his doctor because of severe pain, and the doctor diagnosed early-stage colon cancer. His surgery and treatment would cost upwards of 10 lakhs, over the next year. Realizing this, Mr. Kapoor immediately called his financial advisor and hurried him, to find a no-medical-tests plan - and bought it for a 3 year period. (As you would expect, he did not mention his diagnosis).
In a week, once he had his policy in his hand - he visited another doctor at a different hospital for a fresh (but similar diagnosis). Now, using this diagnosis - he intends to get his entire healthcare bills paid by the insurer.
While this might sound outlandish, such events are known to happen. And, in order to protect themselves from such frauds, and remain viable in the long run, insurance companies impose ‘Waiting Periods’. During these waiting periods, based on certain terms, the insured cannot claim for specific treatments/conditions. Slowly, with time, however, the plan opens up to include more and more conditions.
In this article, we’ll specifically talk about one type of waiting period in health insurance, called the pre existing disease (or PED) waiting period.
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What are Pre Existing Diseases & What is a Pre Existing Disease Waiting period?
The IRDA defines a pre existing disease as any medical condition that was diagnosed or treated (or treatment recommended) in the 36 months (3 years), prior to the purchase of the policy. All health insurance plans impose a waiting period of up to 36 months (3 years) for such pre existing diseases.
Let’s look at an example below.
Say you’re diabetic and have been taking oral medicines for a few years. When you apply for health insurance, you’ll be required to make declarations about the first diagnosis of diabetes, medicines taken, duration of treatment, etc. Based on this information and any pre-policy medical test requested by the insurance company, a certain waiting period on ‘diabetes and related conditions’ is imposed in your policy. Say the pre existing disease waiting period is 3 years. During the first 3 years after your policy is issued, your health insurance will not pay for any treatment taken for diabetes and related ailments.
Now, consider another scenario. Say someone had a medical condition in their childhood, say tuberculosis. They have not undergone any treatment for Tuberculosis in the last 36 months. Now, that person is 25 and wants to buy a health plan. Can the insurer apply a waiting period on that medical condition? Well, No. To understand this, go back to the definition of a Preexisting Disease - since your medical condition did not involve a diagnosis or treatment in the last 36 months, this cannot be considered a PED. And no waiting periods can be imposed on them.
IMPORTANT: Sometimes, insurers might classify such diseases as PED based on your symptom declarations, but you can contest this, and ensure that there’s no waiting period imposed for such conditions.
In this case - should you even mention such old conditions in your declarations? What difference does it make?
Yes - regardless of when they occur - you must declare all your past and present health conditions, treatments, and procedures to the insurer - even if they’re cured. The insurer will use this information you declare, to make a proper assessment of your health status - and make important decisions about whether or not the policy can be issued to you (and if yes, at what cost).
However, they can only impose a waiting period on PEDs - conditions diagnosed or treated in the last 36 months. We’ve collated some more examples in the table below to illustrate the difference between medical history and a pre-existing disease.
History of the condition | Age when is the policy being bought | Should you inform the insurer about this condition? | How will it impact your waiting periods? Appendectomy at Age 12 | 25 years | Yes. You should inform them, as part of your medical history. | Since the illness was treated before 36 months of buying the policy, the pre existing disease waiting period will NOT apply. Skin infection at age 20. Treated and cured. | 22 years | Yes. You should inform them, as part of your medical history. | Since the illness was treated in the last 36 months, Pre existing disease waiting periods of 2-3 years will apply. (based on the insurer) Diabetes diagnosed at age 20. Taking treatment ever since. | 30 years | Yes. You should inform them, as part of your medical history. | Pre existing disease waiting periods of up to 3 years will apply. (based on the insurer) Anxiety issues were diagnosed at age 22. Treatment not taken. | 24 years | Yes. You should inform them, as part of your medical history. | Pre existing disease waiting periods of up to 3 years will apply. (based on the insurer) Hypothyroidism was diagnosed at age 25. Treatment only started after age 30. | 33 years | Yes. You should inform them, as part of your medical history. | Pre existing disease waiting periods of up to 3 years will apply. (based on the insurer)
If you notice above, the thumb rule is that - every condition you’ve ever had - you must inform the insurer, as part of the medical history.
Note: Earlier, a pre-existing disease was any disease or condition that was diagnosed, treated, or sought medical advice in the last 48 months. This has been changed to 36 months, from 1 April 2024. The maximum waiting period for pre-existing diseases, too, has been reduced to 36 months from 48 months.
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Understanding the phrase - “To the best of your knowledge”
You’re required to provide your medical history - “to the best of your knowledge” - meaning you meticulously gather information from all sources available to you. We’ve written an article about how one can take a thorough medical history of parents, but you can easily modify the same checklist for yourself as well.
What about conditions the insurer doesn’t ‘ask’ you about, in the form?
Then there’s a question of whether you should declare any condition or treatment - that the insurer doesn’t specifically ask you about. Most health insurance forms come with a list of common diseases that the insurer wants to check - diabetes, hypertension, hypothyroidism, cancer, etc. In addition to this - they’ll usually impose a very generic question in the lines of - “Any other conditions?”
This is the trick question.
This is where you must declare every minor or major illness, injury, surgery, treatment, etc. you’ve gone through. If there’s no space in the form - go ahead and attach a sheet - but make sure you’ve declared everything to the “best of your knowledge”.
Remember - no insurer is obligated to offer you health insurance cover. Essentially, health insurance is a contract - where based on an assessment of your health, past conditions, and declarations - the insurer estimates the risk you carry. Based on the declarations you make, if the insurer decides that they cannot afford to cover you, they can reject your proposal to buy the health insurance policy.
But that doesn’t mean you should hide details, or lie on your proposal form, just to get the policy approved!
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What can happen if you do not make accurate declarations?
If your declarations are incomplete or false - the insurer can, at any time (on learning about these gaps) refuse to pay your claim, or even cancel your policy altogether. So, always make complete, accurate, and truthful declarations.
Hope this article helps you get more clarity on the definition of pre existing disease in health insurance, waiting periods, and the many questions you might have had around how insurers treat them from an underwriting perspective. If you still have a question, or would like to learn more about a health insurance topic - do post a question on the MyInsureBuddy Insurance Forum and get answers from experts in 6-8 hours!