Pre Existing Disease in Health Insurance

Whether you have a retail health insurance plan or a group health insurance plan, the concept of pre existing disease or PED is vital to understand

This article will highlight the definition and importance of pre existing diseases and conditions

Why Is the Clause of Pre Existing Disease Important in Health Insurance?

The rule book of health insurance as it stands today states that once issued a policy, the same cannot be cancelled or a claim denied by the insurance company ever in future. In retail plans, neither can the premiums be increased in subsequent years based on the health condition. There is however an addendum to this. A policy can still be cancelled or claim denied on 3 grounds namely –

  1. Fraud committed by you or on your behalf
  2. Non cooperation with the insurance company at the time of the claim
  3. Non-declaration, Mis-declaration or Partial-declaration in the proposal form at the time of taking the policy

It is this last point that makes pre existing clause important. If the policy does not cover pre existing diseases for a specific period, then any claim will not be paid. Even if it is declared or not. In certain cases, especially retail plans, the insurer also reserves the right to cancel the policy for non-declaration of pre existing diseases or conditions

What is Pre Existing Disease

How we define a pre existing disease is

Any sign or symptom, for which the policyholder may or may not have taken medical advice or treatment, hospitalisation due to that or its complications, is called pre existing disease. This is applicable to all such signs and symptoms that you may have before the date of taking the health insurance policy.

But I thought pre existing disease in health insurance was limited to real problems ?

You are right. Often for most people, it means Blood Pressure, Diabetes, Cardiac Problems and such larger conditions. In reality you may have aches and pains, fractures and long back issues which are almost forgotten, they are also included

Often we may have infections that lead to Malaria, Gastroenteritis, Dengue and the like. Some common examples of pre existing diseases and conditions that are over looked are –

  • Tuberculosis
  • Migraine
  • Fractures
  • Aches and Pains – like Back Ache, Joint Aches
  • Heavy bleeding and irregular periods
  • Skin disorders
  • Lifestyle including smoking and drinking alcohol

Illustration of Pre Existing Disease and Condition

Let’s take an example, if someone aged 63 years goes to a doctor with a complaint of knee pain. Once MRI is done and is advised Unilateral Knee Replacement, the process for claim starts under health insurance. On being asked by the doctor for history, the patient narrates an accident in younger days that had impacted the knee. Such a declaration to the doctor and subsequent mention on the prescription, which when goes to the insurer for knee replacement claim, may be denied on grounds of the ailment being a complication arising out of a pre existing issue. This may lead to denial of claim.