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Did you know that healthcare inflation in India is increasing at double the rate of overall inflation? Buying an affordable health insurance is the only way to safeguard your finances against the steep cost of quality medical treatments.

However, not every health complication may be covered under health plans. If you suffer from health disorders when you buy the policy, you will need to understand the terms and conditions applicable to such illnesses. Otherwise, you may face claim rejections later. Therefore, it is crucial to know what insurers consider pre-existing diseases and the rules regarding coverage for such ailments.

What are pre-existing illnesses?

The Insurance Regulatory and Development Authority of India (IRDAI) has set clear rules for health conditions considered as pre-existing. According to IRDAI, a pre-existing disease (PED) means any ailment, condition, or injury:

  1. a) that a healthcare practitioner diagnosed within 48 months before the effective date when the insurer issued the policy, or
  2. b) for which you received treatment or medical counsel from a doctor, or a physician recommended any medical advice, within 48 months before your policy start date

Why do health insurance companies not cover PED?

The likelihood of undergoing treatment for an existing ailment is a known risk. If health insurance companies cover pre-existing conditions, then everyone will take insurance only after they have been affected. Then every policyholder will raise claims, which can lead to financial losses for the insurance provider.

Insurance companies, however, do cover PEDs if the policy remains active for four years and it is renewed thereon. This time gap from the policy instatement date is known as the waiting period.

What is “waiting period” in health insurance?

Most health insurance providers cover PEDs after a pre-defined period starting from the policy inception date. It is called the “waiting period.” During this phase, your policy does not cover medical bills for your PEDs.

The duration depends on your insurer and the disease type. However, the maximum interval is usually four years. If you continue paying your premiums, after the waiting period your insurer will settle claims for PEDs.

How does PED affect your health insurance premium?

If you suffer from a PED, the insurer may specify a waiting period. At the end of this period, the insurer may cover your PEDs for the regular premium amount.

In some cases, the insurer may provide instant coverage for PEDs, but ask for a larger premium. This extra amount covers the increased risk the insurer faces in insuring a person already affected by a medical condition.

However, in critical cases, both the waiting period and premium loading might apply.

What are the major exclusions for PED in health insurance?

1. Congenital heart diseases

2. Stroke

3. Chronic liver, kidney, and pancreatic diseases

4. Hepatitis B


6. Loss of Hearing

Which health insurance plan should you buy?

If you need coverage for PEDs, buy a health insurance policy that features:

1. The shortest waiting period

2. Scope to cover most of the PEDs

3. Unrestricted age of entry, if you want financial cover for dependent parents

You can consider theĀ LifelineĀ health plan by Royal Sundaram. The Supreme Plus variant reimburses costs incurred due to PEDs in life-threatening unforeseen emergencies. It does not restrict the maximum age of entry and covers daycare procedures and annual health check-ups. Thus, it also serves as a viableĀ senior citizen planĀ for elderly patients requiring frequent medical care.

If budget is a constraint, you can get theĀ Arogya Sanjeevani PolicyĀ offering standard health coverage at affordable premiums.


Do not back away from purchasing health insurance fearing higher premiums for PEDs. Even with the higher premium, you remain financially secure. PEDs might suddenly aggravate, causing hospitalizations. Your insurance policy will cover your medical bills, allowing you to get the best possible treatment.


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6 responses to “Why do Health Insurance companies not cover pre-existing diseases?”

  1. Dilip Sharma says:

    Useful post. But, Be careful of PED clause of 4 yrs bcoz insurance companies have changed their policies to include only the base cover and exclude cumulative (loyalty) bonus cover.

  2. shrawan deore says:

    It is very useful information. Thanks.

  3. kutumbarao says:

    ur apprehension that all will opt for health ins if PED
    r also covered is not strictly valid if percentage of health conscious persons who have taken health insurance is taken out of total life insurance taken persons and if PED OPTION IS GIVEN WITH UR TERMS AND CONDITIONS IT WILL GO ALONG WAY in bringing those who r yet to decide.Ins is one of chance and not one of certainty

  4. louis vuitton says:

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  5. T.S. Chandra says:


  6. Tushar says:

    Who decides Pre-Existing diseases? Royal Sundaram? What is the level of expertise of these people?
    I am sure accountants decide this based on the claim amount. Otherwise you would be giving proper logical explanations for claim rejections under tis clause rather than stating “prescriptions indicate that this is pre-existing disease.”
    I am not sure about others but Royal Sundaram rejects claims under this clause ONLY BASED OF FINANCIAL CONSIDERATIONS.

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