Health Insurance Policies - Fine Prints - Pre-existing Diseases

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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

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ila_upadhya

what are ENT daycare procedures?

rajmiba2001

Hi, My father [Age-62yr] underwent Cardiac by-pass surgery in 2006 and after that he undergoes annual cardiac check-up every year. He is in good health now. I want to take a Mediclaim policy for him which covers him for any possible future hospitalization (for all generally covered diseases including his pre-existing condition). Please recommend me good options which is also not very expensive.

Hi, I reside in a Metro city and my child is admitted in a Child Care Centre / Nursing Home last night due to illness last night. However the Nursing Home is a small one and has 5-6 beds only. But it is registered one under the regulatory authorities. I seek clarification on below: "HOSPITAL/NURSING HOME: means any institution in India established for indoor care and treatment of sickness and injuries and which either Is duly licensed and registered as a Hospital or Nursing Home with the appropriate authorities and is under the supervision of a registered and qualified Medical Practitioner. OR In areas where licensing and registration facilities with appropriate authorities are not available, the institution must be one recognised in locality as Hospital / Nursing Home andshould comply with minimum criteria as under: [1] It should have at least 15 in-patient medical beds in case of Metro cities, A Class cities......................." Will I be able to claim for reimbursement? Regards, Sameer

My Wife was Pregnant and was in 9th month. All was normal but one night we finish our dinner and went to our bed. But suddenly at midnight my wife found Heavy Bleeding. We immediately run for our Doctor treating her. She refer us to one of the Big n Best Hospital of our city. The problem raised is called Ante partrue Hemarhage [APH] according to Doctor. As due to heavy bleeding my wife was almost in shock. And to save the life of both (Baby n Mother) a Emergency LSCS was done. A baby born via Cesarean. So, I submit a file for claim against my Medical Policy with United India Insurance Co. but that was rejected by saying "Treatment arising from or traceable to Pregnancy (including Caesarean) not covored. But as per me, as My Wife have no Labour Pain nor the whole process was done because of or for Delivery. So, kindly guide me for the same. Should I go to Insurance Ombudsman???

bchandra

I am 26 years old and I would like to undergo Lasik Operation. My sight is -7 in both eyes. Can I get free operation in Hospitals?

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