Pre-Existing Disease (PED) in Insurance

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What is Pre Existing Disease Cover in Health insurance and How Does It Work?

Some of us carry a bit of medical history with us, whether it's a past surgery, an old injury, or a long-term condition like diabetes or hypertension. These are known as pre-existing diseases. But is there any medical insurance for pre existing conditions?

Yes, and understanding what qualifies as a pre existing disease and how it works in your health insurance policy can save you from emergencies later. Let’s explore PED in health insurance.

Team Digit

What is a Pre-Existing Disease?
List of Pre-Existing Diseases in Health Insurance
Why is it Crucial to Disclose PED?
What Happens When You Don’t Disclose?
Waiting Period for Pre-existing Diseases
How Pre-existing Disease Work?
Why Claims Get Rejected?
Do’s and Don’ts
Frequently Asked Questions

What is a Pre-Existing Disease?

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 48 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.

Importance of Pre-Existing Disease Coverage in Health Insurance

Pre-existing disease coverage is a lifeline in health insurance, ensuring that your past health conditions don't drain your finances. Here are some reasons why having pre-existing coverage is important:

List of Pre-Existing Diseases in Health Insurance

The list of pre-existing conditions that are included in health insurance plans are:

Tuberculosis	Renal Cyst
Diabetes	Arthritis
Varicose veins	Cataract
Dengue	Hepatitis
Blood Pressure	Heart Disease
Bronchitis	Thyroid Disorder
Hernia	High Cholesterol
BMI	Asthma
Epilepsy	Sclerosis

Disclaimer: The above conditions are a general representation of PED. Coverage and exclusion for these conditions may vary depending on your health insurance policy. Please read your policy document thoroughly to understand the coverage.

Why is it Crucial to Disclose Pre-Existing Disease Before Buying Health Insurance?

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.

Importance of Declaring Pre-Existing Disease

Do you think hiding your pre-existing disease won’t affect your insurance?

Think again! Not disclosing a pre-existing disease can lead to cancelling your health insurance policy. So, transparency is key to avoiding claim rejections and policy cancellations. Watch the video to know the importance of declaring your pre-existing disease to your insurer.

What Happens When You Don’t Disclose Your Pre-existing Disease?

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.

What is the Waiting Period for Pre-existing Diseases in Health Insurance?

Most policies include pre-existing condition insurance, but there is a waiting period 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 4 years, depending on your health insurance provider and the kind of plan you select.

Types of Waiting Periods in Health Insurance Policy

So, what are these waiting periods we were talking about? Well, there are actually a few different types of health insurance. Let’s go through some of the most common ones:

Types of Waiting Periods	Description	Duration
Initial Waiting Period	An initial waiting period refers to the amount of time you’ll have to wait from the date of issue to start using your health insurance actively.	30 days
PED Waiting Period	A PED waiting period refers to the amount of time you need to wait for any condition that was diagnosed up to 48 months before buying a health insurance policy, such as diabetes, hypertension, thyroid, etc.	1 to 4 years
Specific Disease Waiting Period	Waiting periods for specific diseases imply that you will need to wait the prescribed amount of time to claim treatment for a list of specific diseases such as hernia, cataract, fistula, etc.	1 to 2 years

Disclaimer: The above-mentioned waiting periods are the standard durations provided by insurers across the industry.

How Pre-existing Disease Work in Health Insurance?

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.

Know the Steps to Buy Health Insurance Plan

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 48 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.

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.

Waiting Period for Coverage

Most insurance policies impose a waiting period for pre-existing diseases, typically 1 to 4 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.

How Does Pre-Existing Disease Affect Health Insurance Policy?

Things You Should Know about Pre-Existing Conditions in Health Insurance

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 2-4 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!

Why Claims Get Rejected for Non-disclosure of Pre-existing Disease Post-Waiting Period?

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 2020 with a 2-year waiting period, and he didn't disclose his blood pressure problem.

Later, in 2024, 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.

Do’s and Don’ts for Pre-Existing Disease

The key to grasping each information about PED is by knowing what to do — and what to avoid. Let's review some crucial rules for choosing health insurance for pre-existing conditions.

Do’s	Dont's
Be honest about any existing medical conditions to avoid claim rejections later.	Take time to compare policies and understand how each insurer handles pre-existing conditions.
Look for policies with shorter waiting periods for pre-existing conditions.	Avoid choosing a policy without checking the waiting period.
Understand the policy's limits or caps on treatments related to pre-existing conditions.	Be aware that premiums may be higher for policies covering pre-existing diseases.
Carefully review the policy terms and conditions to know how pre-existing diseases are covered.	Don’t assume full coverage, as there are some sub-limits over such policies.
Get medical advice & checkups to understand the kind of coverage you may need.	Most importantly, don’t withhold any information you want to discuss.

Hence, it is essential to disclose any PED at the time of purchasing the health insurance policy to avoid any future claim rejections.

Explain it like I'm five

We're making insurance so simple that even 5-year-olds can understand it.

A cycling competition is held in school. All the students that sign up for the competition are told to go through a medical check-up first. One student is found to have sprained his ankle 10 days ago. So, the school tells him that he cannot participate in the competition this month – but he can come back and participate next month. That’s because the student had a Pre Existing Condition!

FAQs about PED in Health Insurance

All

Does health insurance cover pre-existing conditions?

Yes, most health insurance covers pre-existing diseases. However, some insurance providers offer PED coverage as an add-on benefit.

What is the typical waiting period for pre-existing conditions in health insurance?

The waiting period for pre-existing conditions in health insurance varies from 1 year to 4 years. The waiting period is the time you must wait before claiming a policy. This period differs from policy to policy for PED.

How do pre-existing conditions affect health insurance coverage?

Pre-existing conditions affect health insurance coverage, resulting in high premiums, long waiting periods, multiple health checkups, and in fact policy denial.

Are mental health disorders considered pre-existing conditions?

Yes, some mental health disorders are considered as pre-existing conditions. If you have undergone any mental health treatment or were diagnosed with it within 48 months of your policy purchase, it is considered a pre-existing condition.

Can I purchase health insurance if I have a pre-existing condition?

Yes, you can buy health insurance with pre-existing disease coverage to cover any disease you have suffered (as mentioned in your policy).

Is the waiting period for coverage of pre-existing conditions negotiable?

Health insurance providers may shorten the waiting period by raising premiums. These choices are made as per the agreement between the policyholder and the policy provider.

Can an insurance company refuse to cover a pre-existing condition?

Yes, an insurance company can refuse to cover a pre-existing condition in accordance with their terms and conditions.

Can a pre-existing condition affect the renewal of your health insurance policy?

Yes, a pre-existing condition affects the renewal of your health insurance policy. It can increase the waiting period, increase the cost of premiums, result in policy denial, and require multiple health checkups before renewal.

What should you do if your health insurance claim is denied due to a pre-existing condition?

If your health insurance claim is denied due to a pre-existing condition. You can:

Understand the reason for the denial
Appeal the decision of the policyholder
Report the behaviour to IRDAI

How do insurance companies determine whether a condition is considered pre-existing?

Insurance companies determine whether a condition covered is a pre-existing disease by:

Looking at your health report and tests
Considering your doctor’s consultation and slips
Checking if you have undergone treatment for any disease in 48 months

Can you switch health insurance providers if you have a pre-existing condition, and how does it affect coverage?

Yes, you can switch health insurance providers if you have a pre-existing condition. The new company will credit you for any waiting time you've previously completed. You can also modify the coverage and premiums.

What are pre-existing conditions?

Some pre-existing conditions include diabetes, hypertension, kidney problems, asthma, arthritis, etc.

Is there any health insurance company in India that covers pre-existing diseases from day 1?

No, there are no such policies. Generally, the policy requires a 1 to 4-year waiting period for PED coverage.

What if I do not disclose my pre-existing disease?

If you are aware of a pre-existing disease and do not disclose it to your insurer, your claim might be rejected in the future.

How Does Pre-Existing Disease Affect Health Insurance Premium?

When you have a pre-existing disease, you need to buy a cover that covers PED. A higher premium can be charged for such a policy because the insurance provider is taking a chance to cover your pre-existing condition. This high premium will only be applicable when the policy is purchased.

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CIN: U66010PN2016PLC167410, IRDAI Reg. No. 158.

Go Digit General Insurance Limited (formerly known as Oben General Insurance Ltd.) - Registered Office Address - 1 to 6 floors, Ananta One (AR One), Pride Hotel Lane, Narveer Tanaji Wadi, City Survey No.1579, Shivaji Nagar, Pune-411005, Maharashtra | Corporate Office Address - Atlantis, 95, 4th B Cross Road, Koramangala Industrial Layout, 5th Block, Bengaluru-560095, Karnataka | Trade logo of Go Digit General Insurance Ltd. displayed above belongs to Go Digit lnfoworks Services Private Limited and is provided and used by Go Digit General Insurance Ltd. under license.

What is Pre Existing Disease Cover in Health insurance and How Does It Work?

Table of Contents

What is a Pre-Existing Disease?

Importance of Pre-Existing Disease Coverage in Health Insurance

List of Pre-Existing Diseases in Health Insurance

Why is it Crucial to Disclose Pre-Existing Disease Before Buying Health Insurance?

Importance of Declaring Pre-Existing Disease

What Happens When You Don’t Disclose Your Pre-existing Disease?

What is the Waiting Period for Pre-existing Diseases in Health Insurance?

Types of Waiting Periods in Health Insurance Policy

How Pre-existing Disease Work in Health Insurance?

Buying Health Insurance

Mandatory Declaration

Medical Tests & Diagnosis

Impact on Premiums

Waiting Period for Coverage

Coverage After Waiting Period

Claim Settlement

Non-Disclosure Risks

How Does Pre-Existing Disease Affect Health Insurance Policy?

Things You Should Know about Pre-Existing Conditions in Health Insurance

Health Insurance policies differ from one another

Not all ailments are considered pre-existing conditions

Hiding a Pre-existing Condition is never a good idea

You can get coverage for Pre-existing Medical Conditions

Waiver of Pre-existing Disease has a waiting period

Your health insurance provider may reject your claim if you have a pre-existing condition

Why Claims Get Rejected for Non-disclosure of Pre-existing Disease Post-Waiting Period?

Do’s and Don’ts for Pre-Existing Disease

Explain it like I'm five

FAQs about PED in Health Insurance

Does health insurance cover pre-existing conditions?

What is the typical waiting period for pre-existing conditions in health insurance?

How do pre-existing conditions affect health insurance coverage?

Are mental health disorders considered pre-existing conditions?

Can I purchase health insurance if I have a pre-existing condition?

Is the waiting period for coverage of pre-existing conditions negotiable?

Can an insurance company refuse to cover a pre-existing condition?

Can a pre-existing condition affect the renewal of your health insurance policy?

What should you do if your health insurance claim is denied due to a pre-existing condition?

How do insurance companies determine whether a condition is considered pre-existing?

Can you switch health insurance providers if you have a pre-existing condition, and how does it affect coverage?

What are pre-existing conditions?

Is there any health insurance company in India that covers pre-existing diseases from day 1?

What if I do not disclose my pre-existing disease?

How Does Pre-Existing Disease Affect Health Insurance Premium?

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