Pre-existing Diseases
The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any Insured person in connection with or in respect of:
All diseases/injuries which are pre-existing when the cover begins for the first time. For the purpose of applying this condition, the date of the start of the initial mediclaim policy taken from any of the initial mediclaim policies taken from any of the Indian Insurance Companies shall be taken, provided the renewals have been continuous and without any break.
This clause deals with the exclusions of ailments/diseases/injuries in the policy cover of an individual. This exclusion depends upon of such ailments/diseases/injuries or complications arising out of it, existing prior to the commencement (start) of the policy or an ailment that coincides with the beginning of the policy.
A pre-existing (or occurred) ailment/disease/injury having a definite co-relation with an existing diseaseis repudiated. Examples of pre-existing diseases are as follows: COPD (Chronic Obstructive Pulmonary Disease), Asthma, Hypothyroidism, Hyperthyroidism, Heart Ailments, Hypertension, Diabetes Mellitus, Thalassemia etc.
Most disputes occurring in the current scenario between the insurance companies and consumers are related to claims that arise mostly on account of pre-existing diseases. The debate pertaining to the duration of such pre-existing diseases could be some of the reasons following, as listed below:
- The disease may be in existence much before the commencement of the policy
- Disease/Ailment may be in existence but unknown to the policyholder and detected suddenly or during check-up. Examples include Hypothyroidism, hole in the heart, diabetes, hypertension, sickle cell anemia etc.
- Suppressed by the policyholder intentionally
- Policy taken by the patient soon after detecting the disease
- Discrepancy in dates of the ailment, either by the patient or Medical Practitioner or Hospital
- A very fresh policy
Requirement for Claim for Pre-existing Diseases - Based on fresh directives issued by IRDA, certain pre-existing diseases are being covered under the Insurance cover e.g. hypertension and diabetes are being covered only after the policyholder has been possessing a health insurance policy cover for a minimum of two or four or more years without a break in the policy cover. Also no hospitalization should be sought for the pre-existing ailment in those four years (since beginning of the policy cover) and no claim should have been made through any other Insurance Company. A continuous four claim-free years is a pre-requisite to be eligible for the benefit under the clause of pre-existing diseases. This directly implies that no claim should have been made by the claimant with the same or some other insurance company for that particular ailment or its associated complication for deriving the benefits.
The coverage of pre-existing diseases by various insurance companies varies to a great extent. So it is always recommended that the customer keeps himself updated with the latest health-insurance products and services available in the market. To have the pre-existing diseases covered for a particular individual, an additional amount that constitutes the premium needs to be paid for deriving the desired benefits from the policy cover.
If you have any disease you are advised to do some homework before purchasing the policy. You should be careful in your policy selection and have a discussion with your agent or someone senior in the company. It may be better to pay a little more to ensure that your disease is covered by the company.
A quick summary of the position taken by general insurance companies dated November 2009-10, is given below:
| Name of Insurance Product | No of years required for Pre-existing Diseases to be covered | Any special relaxation for existing diseases |
| Apollo DKV - Easy Health Individual – Exclusive | After 3 years of continuous policy years | |
| Apollo DKV - Easy Health Individual – Premium | After 3 years of continuous policy years | |
| Apollo DKV - Easy Health Individual – Standard | After 3 years of continuous policy years | |
| Apollo DKV - Easy Health Insurance - Exclusive | After 3 years of continuous policy years | |
| Apollo DKV - Easy Health Insurance – Premium | After 3 years of continuous policy years | |
| Apollo DKV - Easy Health Insurance - Standard | After 3 years of continuous policy years | |
| Bajaj Allianz - Health Guard | After 4 continuous policy year | |
| Cholamandalam MS General Insurance - Family Floater | After 3 continuous policy years where no claim, care, treatment or advice has been recommended by or received from a doctor in relation to such pre-existing condition during that 3 year period | |
| Cholamandalam MS General Insurance - Individual Health | After 3 continuous policy years where no claim, care, treatment or advice has been recommended by or received from a doctor in relation to such pre-existing condition during that 3 year period | |
| Future Generali - Health Suraksha Family Basic | After 4 years of continuous policy years | |
| Future Generali - Health Suraksha Family Golden | After 4 years of continuous policy years | |
| Future Generali - Health Suraksha Family Silver | After 4 years of continuous policy years | |
| HDFC Ergo - New Healthwise | Not covered | |
| ICICI Prudential - MediAssure (Classic) | Pre existing illnesses and conditions which are declared at beginning and specifically accepted by the company would be covered | |
| ICICI Prudential - MediAssure (Premium) | Pre existing illnesses and conditions which are declared at inception and specifically accepted by the company would be covered | |
| IFFCO Tokio - Individual Medishield | After 3 continuous policy years where no claim, care, treatment or advice has been recommended by or received from a doctor in relation to such pre-existing condition during that 3 year period | |
| National Insurance - Mediclaim Policy | After 4 continuous claim free policy year | |
| National Insurance - Parivar for Family | After 4 continuous claim free policy years | |
| New India Assurance - Mediclaim | After 4 continuous claim free policy year | Yes, from 2nd year, on payment of additional premium |
| Oriental Insurance - Health Insurance | After 4 continuous policy year | |
| Reliance General - Healthwise Silver 1 year | After 2 years of continuous policy years | |
| Reliance General - Individual Mediclaim | Not covered | |
| Royal Sundaram - HealthShield Standard | After 5 continuous policy year | |
| Star Health - Family Health Optima | After 5 years of continuous policy years | |
| STAR Health - Medi Classic | After 5 continuous policy year | |
| United India Insurance - Mediclaim Policy Gold | After 3 continuous claim free policy year | Yes, after paying an extra premium of 30 per cent |
