What Are The Revised Rules For Pre-Existing Diseases As Per IRDAI?

The health insurance regulator has relaxed some requirements for pre-existing conditions, which will benefit policyholders. Changes to the concept of pre-existing disease eliminate uncertainties that could have resulted in claim denials and cancellations.*

The Insurance Regulatory and Development Authority of India (IRDAI) has twice in the past modified the definition of pre-existing diseases. As per the most recent guidelines, a policyholder will no longer be regarded as having a pre-existing condition if diagnosed with a sickness during the first three months of purchasing a health insurance policy. #

What’s the difference?

There were two types of pre-existing conditions. The first are ailments that policyholders have known throughout the policy-buying process. If a person had a sickness 48 months before purchasing health insurance, even if treated, it is considered pre-existing.

The adjustment is made to the second category, which stated that any ailment contracted within three months of policy issuance would also be considered a pre-existing condition. This meant that a heart blockage or diabetes diagnosed within three months of purchasing the policy would be considered a pre-existing condition.*

The maximum waiting period for the pre-existing condition is four years. However, this varies from insurer to insurer and depends on the sickness. You could download a medical insurance app to check and verify as it differs from insurer to insurer. *

How new rules benefit

Until the guidelines were changed last year, the language about pre-existing conditions was vague. It earlier stated that the pre-existing disease means any condition, ailment, injury or related condition(s) for which there were signs or symptoms and was diagnosed and for which medical advice/treatment was received within 48 months before the first policy issued by the insurer and continuously renewed after that.

According to industry analysts, insurers have denied coverage for chronic illnesses based on the previous criteria. Usually, these conditions do not require immediate medical intervention. An insured intending to commit fraud may purchase the coverage and delay treatment for up to a year. Such claims are typically subject to rigorous review, and some insurers denied them even when there were ambiguities.*

There have also been instances where the policyholder was unaware of a pre-existing condition. Even such instances had resulted in the denial of claims and, on occasion, the termination of policies. The regulator introduced a new section to define pre-existing disorders at that time.

The pre-existing disease is now defined as any condition for which medical advice or treatment was recommended or received from a physician within 48 months before the policy’s effective date issued by the insurer or its reinstatement. It can also be checked on the app for health insurance.*

Treatment at the hospital on the blocklist

The regulator has also somewhat loosened the requirements for treatment at hospitals that insurance companies have blacklisted. Before, insurers rejected claims made at a hospital on a blocklist unless the patient was admitted following a life-threatening accident.

Now, policyholders can seek treatment in banned facilities for any life-threatening condition, not only accidents. One can still crosscheck the hospitals to be availed on their medical insurance app.

The regulator has provided policyholders with much-needed relief by removing the majority of misunderstandings in the area of pre-existing conditions. Therefore, while purchasing insurance, ensure that you provide accurate information to the best of your ability. Refrain from relying on the agent to perform this task. The policy may be cancelled if the insurer discovers the client failed to disclose information.

Download the bajaj allianz mediclaim app and crosscheck the information added by the agent on your behalf to avail of the insurance policy. Also, most health insurance policies have a one-month cooling-off period. During this period, only claims relating to accidents will be entertained.*

*Standard T&C Apply

# Visit the official website of IRDAI for further details.

‘Insurance is the subject matter of solicitation. For more details on benefits, exclusions, limitations, terms, and conditions, please read the sales brochure/policy wording carefully before concluding a sale.‘