Many people with pre-existing health conditions worry about getting adequate insurance coverage. If you have hypertension, diabetes, asthma, or any other ongoing medical issue, your health insurance terms may differ.

The Insurance Regulatory and Development Authority of India (IRDAI) defines what qualifies as a pre-existing disease (PED), how long insurers can impose waiting periods, and what coverage you can expect afterwards. Understanding these rules helps you make informed decisions, manage costs and avoid claim rejections.

What is Pre-Existing Disease as Defined Under IRDAI?

The majority of medical insurance policies for pre-existing conditions cover diseases such as high blood pressure, arthritis, diabetes, asthma, heart disease, and thyroid disease, as long as the relevant waiting periods are met. The IRDAI states:

A pre-existing condition (PED) refers to any illness, injury, or disease that was diagnosed by a doctor within 48 months before the start of the health insurance policy, or for which medical advice or treatment was received or recommended during that period.

The typical waiting period for pre-existing ailments should not exceed 36 months.

During the waiting period, no claims in respect of the declared pre-existing condition are payable, except for treatments or conditions under other clauses (if any) or through special riders.

Insurers may offer buy-back PED riders or optional covers to reduce waiting periods, often in exchange for higher premiums.

Types of Health Insurance Policy Structures

Here are some of the policy structures that commonly cover pre-existing conditions, with differences in waiting period, premium and terms:

1. Individual health insurance

It covers an individual and may ask you to disclose your medical history on the application. Insurers will typically impose a waiting period for the disclosed condition and may also charge higher age- and condition-related premiums. This option provides a policy tailored to an individual's health needs.

2. Family floater health insurance

This insures all family members under one sum insured. There are waiting periods for pre-existing conditions for each member, and a single large claim can reduce others' available coverage.

3. Group health insurance

It is available through employers or companies. These policies provide standardised cover to numerous individuals simultaneously. Group plans tend to include more favourable waiting periods for pre-existing conditions, though the benefit and amount insured can be lower.

4. Senior citizen health insurance

These plans are designed for older adults. They typically have higher premiums because health-related risks increase with age. The waiting periods are also longer. You must check which chronic or long-term conditions are excluded and which are covered. These policies primarily focus on the standard healthcare needs that come with ageing.

5. Government health insurance schemes

Public health insurance plans provide coverage to individuals who meet certain eligibility requirements. Several of these plans also include treatment for pre-existing conditions, as outlined in their guidelines. Eligibility, claim process, and benefits can differ greatly from one state or scheme to another.

What to Check Before Picking a Policy

Here are the parameters to check, especially if you have a pre-existing ailment:

• PED waiting period: Check whether the policy has the full 36-month waiting period or offers concessions (e.g., through buy-back riders). The lower the waiting time, the earlier you can claim for your condition.
• Disclosure requirements: Completely disclose your medical history. Concealment of a condition can lead to claim refusals even after the waiting period is served.
• Premium rate and increases: If the condition is severe, premiums may increase. Also, find out whether renewal premiums increase with age or worsening of the disease.
• Sum insured: The treatment for existing or long-term health issues can be costly. You must ensure the sum insured is sufficient to cover regular check-ups, hospital stays, and possible treatments.
• Optional add-ons or riders: Add-on options, such as specified disease covers, PED buy-back riders or critical illness insurance, can help lower the waiting periods or provide additional protection.
• Policy portability and terms of renewal: If switching insurers, arrange for the waiting period or benefits to be transferred.

Factors That Affect the Premium and Coverage

Certain factors can have an impact on the premium and coverage, such as:

• Severity of the condition: When your pre-existing disease is well-controlled or mild, the additional cost is likely to be lower.
• How long you have had the condition: If you have been healthy for many years, the insurance company might see you as a lower risk.
• Age: Older individuals typically pay more in premiums.
• Risk and lifestyle factors: Certain habits, such as alcohol, obesity and smoking, can make you appear at higher risk.
• Provider network and network hospitals: If many reliable hospitals are under the insurance firm’s network near you, it might lower the expenses. However, a limited network can increase the costs.
• Region/location: Premiums depend on the state or city you live in, as medical expenses can vary.

Conclusion

Health insurance for pre-existing diseases is regulated to provide you with clearer timelines and protections. The main rules are that every pre-existing disease (PED) must be honestly declared, the waiting period cannot exceed 36 months and insurance firms may offer special add-ons to reduce this waiting period under specific terms.

When choosing between senior citizen, group, family floater, or individual plans, compare the sum insured, waiting periods, available add-ons, and premiums. Always review the policy documents carefully, share your complete medical history, and choose a plan that aligns with your budget and health needs.