Individual Health Insurance Plans for Pre-Existing Conditions

These days, chronic illnesses are no longer rare. Diabetes, hypertension, and thyroid are all conditions that a large percentage of Indians are usually diagnosed with, and this is typically long before they even consider buying health insurance. Once they receive their initial hospital bill, the first question that pops up is, " Will a medical insurance plan actually cover me?”

The short answer is, yes. Most individual health insurance plans in India cover pre-existing diseases. However, the main difference between them is their waiting periods and other terms. What makes this more complicated is that two plans from different insurers can appear identical on paper but may behave very differently at the time of a claim. This is why having an in-depth understanding of the types of individual health insurance that cover your specific needs is very important. This article covers what exactly PEDs are, how they are covered in individual health insurance plans, and some factors that you should check when making your decision. 

How Do Individual Medical Insurance Policies Cover Pre-existing Conditions?

Any illness or medical condition that you were diagnosed with, treated for, or showed symptoms of within 36 months of buying a policy is classified as a pre-existing disease (PED). Even if you were not formally diagnosed with a condition but had visible symptoms, it will still be counted as a pre-existing disease. So if you reported episodes of chest pain before buying a policy, and later get diagnosed with a cardiac condition, your insurer may still treat it as a PED regardless of when the formal diagnosis was made. 

Common examples of PEDs are: 

• Type 2 diabetes and related hypertension conditions.
• Hypertension and cardiovascular issues.
• Asthma and other chronic respiratory conditions.
• Thyroid disorder.
• Joints and arthritis-related conditions.
• Kidney ailments.

When Does Coverage for a PED Actually Get Activated?

This is where waiting periods become a concern. There are two main types of waiting periods, and a lot of first-time policy buyers end up confusing them: 

Both of them are two separate things. Your PED waiting period runs separately from the initial waiting period and is usually considerably longer. Some plans apply a separate waiting period for specific conditions like cataracts or joint replacements. It is important to check the condition-specific waiting periods before you commit to a plan. 

What Changes Has the IRDAI Made for PEDs?

The Insurance Regulatory and Development Authority (IRDAI) has come up with changes that will ensure that you have a cover for PEDs in an individual policy. As of 2024, the maximum waiting period an insurer can impose for PEDs is now 3 years instead of 4 years.  Insurers are also now required to clearly state all waiting periods and exclusions in the policy document. Some insurers even go further and offer plans with a 1 or 2-year PED waiting period that you can consider.

What Will Be Covered Once the PED Waiting Period Ends?

Once you have completed your PED waiting period, your policy will cover:

• Costs of hospitalisation related to the PED
• Costs of diagnosis and treatments required by the disease, surgery and medication as prescribed.
• Day care procedures
• Pre and post-hospitalisation expenses
• Continuous therapies, follow-up consultation, etc.
• Complications associated with the PED

However, it’s crucial to read your policy carefully; some insurers may impose limits on costs, which might include the sub-limit for specific procedures.

What to Check in Individual Health Insurance Policies for PEDs?

Not all individual health insurance plans treat PEDs the same way. It is important that you check the following: 

1. Shorter Waiting Periods:

   Buying a plan with a 2-year waiting period is significantly better than one with 3 years, specifically if you are older or are already managing a pre-existing condition. Some insurers also offer waiting period reduction riders. A waiting period reduction rider is an add-on that you can purchase with your insurance policy. It allows you to shorten the waiting period for PEDs by paying an additional premium. However, if you are buying at a younger age with a mild or well-controlled condition, then you may qualify for a shorter waiting period without requiring an additional rider. 

    

2. Adequacy of Sum Insured:

   A chronic condition usually means frequent hospitalisation and tests, which can add up to a substantial amount. A sum insured of ₹5 Lakh might seem enough at the moment, but if you are suffering from a kidney or cardiac issue, then you could easily exceed that amount in a single hospitalisation. It is important that you consider your specific PED and the treatment costs to ensure that the sum insured is truly adequate for you. If budget is a constraint, a base plan of ₹5 Lakh with a super top-up can increase your coverage significantly without causing a drastic increase in your premium.

    

3. Cashless Hospital Network:

   If you find yourself in the middle of a health emergency, the last thing you would want is to arrange for medical expenses out of your own pocket. Check that your insurer has a wide cashless network of hospitals, particularly near where you live and where you are likely to seek treatment from. 

    

4.  Lifetime Renewability:

   This is a non-negotiable factor. Chronic conditions typically require long-term treatment, and a plan that can be easily cancelled or not renewed once you develop complications can be harmful. Confirm that your policy offers guaranteed lifetime renewability. 

    

5.  Cover for Chronic Disease Management:

   Some policy plans now include benefits like annual health check-ups, OPD consultations, and treatment-specific management programmes, specifically for diabetics or cardiac patients. They can also offer coverage for certain medical procedures like dialysis, joint replacement, and cardiac care. This can prove to be useful over time, specifically if your condition requires regular monitoring and medication. 

    

6.  Co-payments, Sub-limits and Exclusions:

   Make sure that you carefully read this section of your policy document. If a co-payment clause for PED-related claims exists, you will have to bear 10 to 20% of every claim out of pocket. Some sections can also specify a cap for room rent or specific procedures. These details directly impact how much you actually pay and how much is covered by your policy. 

    

7. Affordability of Premiums Over the Years

   Just like any policy that provides a low sum insured for a very low premium, you can expect your premium to rise considerably when you renew the policy. Always make sure to compare not just the entry premium but also the insurer’s track record on renewal pricing and how premiums tend to change as you age. 

    

How Do I Choose an Individual Health Insurance Plan According to My Needs?

There is no single individual health insurance policy that works for everyone. The ideal one depends on your specific condition, budget, and healthcare habits. These are some guidelines that you should keep in mind when buying an individual health insurance policy: 

• Compare waiting periods for PEDs

Do not make your decision simply based on the premium amount. Two plans priced similarly might have very different PED waiting periods or disease-specific exclusions. Compare three to four plans side-by-side before actually making a decision.  

• Check exclusions carefully

Some plans entirely exclude specific conditions permanently. Others tend to exclude any complications that arise from your PED, even after the main waiting period ends. You must check the exclusions and ensure that it actually covers all your needs. 

• Predict your future healthcare needs

Think five to ten years ahead. If you are managing a condition that is likely to progress, make sure you actually take that into account. Someone with a heart issue might need a much higher sum insured than someone with a mild and controlled thyroid condition. 

• Consider the utility of a top-up plan

If a comprehensive base plan feels too costly, then a base plan that is combined with a super top-up plan can offer more financial help at a lower combined premium. However, remember that these top-up plans typically have their own waiting periods and terms. 

• Buy a policy much sooner than later

The longer you wait, the higher your premium will get and the stricter the terms and conditions. If you buy an individual health insurance policy at a young age while your condition is well-controlled, then the clauses in your policy might work in your favour more. 

To Sum it Up 

No single plan is universally the best for every pre-existing condition. What works for someone with hypertension may not necessarily suit someone with a more complex condition. The right individual health insurance plan should have a manageable waiting period, an adequate sum insured, and premiums that you can realistically sustain over the long-term. 

If you are looking for a starting point, then we at Niva Bupa offer a variety of individual health insurance plans that are designed for patients with PEDs. These come with the benefits of smaller waiting periods, add-ons for chronic conditions, and extensive cashless networks for Indian hospitals. We ensure that our health insurance plans are built with transparent and straightforward terms, which can make comparing and making your decision much easier. 

Remember not to procrastinate on your individual health insurance plan. The sooner you buy, the quicker your waiting period ends, and the better protected you will be when it matters the most. 

FAQs

1. Can an Insurer Reject My Application Because of a Pre-existing Disease?

   Yes, insurers can check your medical history before they issue a policy to you. A lot of insurers do provide coverage for common PEDs, but they may add waiting periods, exclusions, higher premiums, or additional medical tests. 

    

2. What Happens If I Do Not Disclose a Pre-existing Condition While Buying Health Insurance?

   Failing to disclose a known PED can lead to the rejection or cancellation of your claim or your policy plan entirely. It is always good practice to provide a complete and accurate medical history to your policy provider. 

    

3. Can I Switch to Another Insurer If I am Unhappy with My Current PED Waiting Period?

   Yes. You can port your health insurance policy to another insurer. Under IRDAI guidelines, you may receive credit for the waiting periods that you may have already served. However, this still depends on your new insurer’s terms and conditions.