Pre Existing Disease Cover in Health insurance

Once you know the full-form, it sounds a lot simpler! PED stands for ‘Pre-existing Diseases’ or Pre-existing Condition, and is an important factor in your health insurance. It basically refers to the diseases or ailments you were suffering from at the time you bought your policy.

According to IRDAI, a “pre-existing disease” in insurance is any illness you were suffering from and diagnosed with 36 months before you bought your health insurance policy.

PEDs can range from serious medical conditions like cancer or diabetes to ailments like blood pressure or allergies.

So, imagine your doctor diagnoses you with asthma and writes you a prescription for asthma medication, and you buy insurance one year later. Then, your health condition – that is, asthma – is a pre-existing condition.

You may be wondering if it’s worth declaring your pre-existing condition in the first place. But in this case, it’s best to be as transparent as possible!

Why?

If you hide your pre-existing condition from your insurance provider, they will find out about it later. They may not cover it at all. So, it’s better to wait a while and get your PED covered than not declare it! Go through your medical files to ensure you have included all the diseases and treatments you would need to be covered.

When purchasing health insurance, if you fail to disclose a pre-existing condition (PED), you run the risk of having your policy cancelled and facing additional penalties, such as:

• Refusal of Claim: Your insurer can reject a claim you make for a disease you did not disclose.
• Limitations on Coverage: Your coverage could be restricted even if your claim is accepted.
• Policy Cancellation: Your insurer can cancel your policy if you deliberately hide a pre-existing disease.

Most policies include pre-existing condition insurance, but there is a waiting period in health insurance of a few years before the condition is covered. The number of years depends on your age and your condition. 

The waiting periods for pre-existing diseases typically range from 1 to 3 years, depending on your health insurance provider and the kind of plan you select.

Understanding how pre-existing diseases work in health insurance is crucial for staying protected from financial burdens in future. Here is a breakdown of how pre-existing diseases work in health insurance: 

Buying Health Insurance: Buying a health insurance policy with PED coverage is a crucial first step in safeguarding your financial future. You can buy the plan as per your specific needs.

Mandatory Declaration: When buying a health insurance, it is essential to disclose any pre-existing disease to your insurance provider. It includes any illness you suffered and diagnosed with 36 months before buying your insurance policy.

Medical Tests & Diagnosis: Insurers may ask for medical tests before offering you coverage to assess the risk of insuring you with a PED condition. Based on your diagnosis test results, your insurer will decide the premiums, coverage and sum insured in health insurance.

Impact on Premiums: Health insurance policies covering PEDs often come with higher premiums. Insurers assess the increased risk of covering an individual with an existing condition, which may result in a higher cost. The premium is decided based on your disease and coverage. 

Get to know: How to calculate the Health Insurance Premium?

Waiting Period for Coverage: Most insurance policies impose a waiting period for pre-existing diseases, typically 1 to 3 years. This waiting period differs from policy to policy. During this period, claims related to PED are not covered, but claims related to any other problems, such as accidents or illnesses (as per your policy), can be covered. 

Coverage After Waiting Period: Once the waiting period is over, the health insurance policy covers treatment costs for pre-existing diseases incurred after the waiting period. The coverage will depend on your policy terms and conditions. 

Claim Settlement: If the waiting period is over, claims related to PED expenses encountered after the waiting period may get approved as per the policy’s coverage limits. 

Non-Disclosure Risks:  If pre-existing conditions are not declared at the time of policy purchase, they may lead to claim rejections even after the waiting period is over.

These are some crucial details about pre-existing conditions in a health insurance that you should be aware of:

Health Insurance policies differ from one another: And so do the terms and conditions with respect to pre-existing conditions. You should always check for waiting periods and the list of PEDs that are covered by your health insurance policy.

Not all ailments are considered pre-existing conditions: Not all ailments or visits to the doctor are considered as pre-existing conditions. Insurers only consider medical conditions and ailments that have had a long-term effect on a person’s health.

Hiding a Pre-existing Condition is never a good idea: We often think we should hide the facts that might hinder our chances of getting health insurance, like a pre-existing condition. However, this can lead to a reverse effect, where even if you get a health insurance policy by hiding a PED, your claim might get rejected.

You can get coverage for Pre-existing Medical Conditions: We often think that PEDs cannot be covered. However, various health insurers offer the benefit of a "Waiver of Pre-existing Condition" that covers PEDs and covers expenses related to them.

Waiver of Pre-existing Disease has a waiting period: For your health insurance policy to cover PEDs, often insurance companies have a waiting period of 2 years. So, you should start early with your health insurance policy.

Your health insurance provider may reject your claim if you have a pre-existing condition: But if you get a waiver of PED cover, your pre-existing conditions will also be covered in your policy. Most insurance providers have a 1-3 year waiting period for pre-existing conditions. This means that you’ll have to wait that long for your insurance provider to start covering your PED!

When a person doesn't disclose their PED to their insurance provider at the time of purchasing an insurance policy, it is considered as non-disclosure of pre-existing disease (PED). In such cases, the claims get rejected, or your insurer might apply a limitation on the coverage. 

For example, Mr. Rutvik bought a health insurance plan in 2021 with a 3-year waiting period, and he didn't disclose his blood pressure problem. 

Later, in 2025, Mr. Rutvik was hospitalised due to high BP and thought that his insurance company would cover the cost as the waiting period was over. However, his claim was denied since he had a PED and did not report it at the time of purchase.

Read: What to Do if Your Health Insurance Claim is Denied?