Waiting Period in Health Insurance

You’re probably here because you noticed there’s something called a waiting period in health insurance and like many others who are buying a health insurance policy for the first time, you aren’t sure what it means, and if there is something called a waiting period- how long is it and what does it include?

Well, keep your doubts at bay and read on for everything you need to know about waiting periods in your health insurance.

As the name suggests, waiting period is quite literally the amount of time you need to wait. And in a health insurance, it refers to the amount of time you need to wait for, from the start of your policy, to be able to use the benefits of it.
For example: One of the most common types of waiting period is the time you need to wait to be able to use special benefits such as a Maternity Cover; in this case most health insurers will include a waiting period of 2-4 years i.e. before you can actually benefit from the maternity cover, you should have your policy for at least 2 years (the amount of time is dependent on the health insurance policy you buy).

There are various kinds of waiting periods present in every health insurance policy. Let’s have a look at what they imply, what the industry average is, and what is Digit’s Health Insurance waiting periods in context to them all.

1. Initial Waiting Period

An initial waiting period, also known as the cooling period in health insurance, refers to the amount of time you’ll have to wait from the date of issue to actively start using your health insurance policy and benefiting from it.Today, the industry standard for initial waiting periods is up to 30 days for all health insurance policies.

2. Pre-Existing Diseases Waiting Period (PED)

Typically, when you buy a health insurance policy, you will be asked about pre-existing diseases and/or will also be asked to take a few medical tests that may conclude the same.

According to the IRDAI, a pre-existing disease refers to any condition, ailment, injury, or disease that was diagnosed up to 48 months before buying a health insurance policy.  

Some examples of pre-existing diseases include diabetes, hypertension, thyroid, etc. Therefore, if you do have a pre-existing disease, you will have to wait for the prescribed waiting period before you can claim any hospitalization or treatment that is related to the disease.
Usually, the waiting period for pre-existing diseases is 1 to 4 years, depending on your health insurer and the type of health insurance plan chosen.

3. Waiting Period for Specific Diseases & Surgery

The title is perhaps self-explanatory, i.e., waiting periods for specific diseases and surgeries imply that you will need to wait for the prescribed amount of time when it comes to claiming treatment and hospitalization related to a list of specific diseases and surgeries. 

Generally, the waiting period for these situations is 1 to 2 years.

Here’s the list of diseases:

4. Maternity Benefit & Newborn Baby Cover Waiting Period

As part of most health insurance policies for individuals and families, there is an option to also include a maternity benefit and newborn baby add-on for those planning a family soon, and apart from just planning for the baby, it is wise to also plan financially for the expenses that arise during and post labor.

Typically, the waiting period with most health insurance policies ranges from one year to four years.

This means you can only claim for maternity-related expenses once you’ve completed two years of your policy.

Therefore, if you’re planning on starting a family sometime soon and want to ensure your health insurance policy covers it, then take into consideration the 9 months of the pregnancy term, plus the rest 15 months to complete your two-year waiting period.

The maternity benefit add-on covers delivery expenses and the baby for its first 90 days; including its necessary vaccinations and any other medical care required otherwise.

Know more about:

• Health insurance with Maternity Cover
• Health Insurance Covering OPD Expenses

5. Waiting Period for Accidental Hospitalization

Accidents can cause the most unexpected injuries and other medical concerns. Therefore, given the nature of accidents, all health insurers, including Digit, do not account for any waiting period when it comes to accidental hospitalizations. This means one can claim for accidental hospitalizations even just days into their new health insurance policy. The initial waiting period doesn’t apply here either.

The waiting period is the time you need to wait before you can use your health insurance policy for specific treatments or conditions. For example, if your policy has a waiting period of 30 days, you can’t claim benefits for any illness or injury that occurs during this 30-day period. Waiting periods vary based on the insurance plan and the specific condition.

Let’s explore how waiting periods in health insurance work through a practical example.

Kiran buys a health insurance policy on January 1st. His policy includes a 30-day initial waiting period for any illness-related claims.

In Case of Initial Waiting Period

According to his policy, the initial waiting period is 30 days. This means Kiran cannot make a claim for any illness or medical condition that occurs within the first 30 days after purchasing the policy.

On January 15th, Kiran develops a cold and needs to see a doctor. Since this illness occurred within the 30-day waiting period, it is not covered by his insurance policy.

He pays for the treatment out of his own pocket.

On February 1st, the 30-day waiting period ends. Kiran’s policy is now active for all covered illnesses and medical treatments.

If Kiran develops another illness or requires medical treatment after February 1st, he can make a claim under his policy, provided the treatment is covered and adheres to other policy conditions.

In Case of Pre-Existing Disease Waiting Period

Suppose Kiran has diabetes, which he had before purchasing the policy. His policy has a 2-year pre-existing disease waiting period.

Kiran can’t claim benefits for diabetes-related treatments until 2 years have passed from the policy start date.

If he requires treatment for diabetes in the first 2 years, he will need to cover those expenses himself. After the 2-year waiting period, he can claim benefits for his diabetes treatment as long as it’s covered by the policy.

Health insurance plans have waiting periods to protect the insurance company from immediate claims. This means that after buying an insurance plan, you might need to wait for a certain period before you can claim certain benefits. 

Here are three main reasons why health insurance plans have waiting periods:

• To Prevent Fraud

Waiting periods help prevent people from purchasing health insurance only when they need immediate medical care. Without waiting periods, individuals could buy insurance just before a major medical event, knowing they would immediately claim expensive treatments. This would lead to financial losses for insurance companies and higher premiums for everyone.

• To Encourage Long-Term Coverage

Waiting periods promote continuous coverage and discourage short-term or temporary use of insurance. This means that the insurer collects premiums over time before paying out significant claims, which helps maintain financial stability and enables them to cover the costs of long-term medical care for their insured members.

• To Manage Risk and Costs

Waiting periods help insurance companies manage the financial risks and costs associated with covering various medical conditions. Certain medical conditions or treatments can be very costly. Waiting periods allow insurance companies to spread out the risk of high claims over time. For pre-existing conditions or specific diseases, waiting periods give insurers time to better assess and manage the financial impact of these risks.

A zero waiting period means that you can start using your health insurance benefits for the specified illnesses immediately after buying the policy without having to wait for a specified period. This is usually found in specific plans or for certain types of coverage, like accidents.

With a zero waiting period policy, you don’t have to wait any time at all to make a claim. As soon as your policy is active, you can use it for covered treatments or expenses. However, zero waiting periods are often applicable to only certain types of coverage, like emergency treatments, and may not cover pre-existing conditions or specific diseases immediately.

Let’s understand with an example.

Riya buys a health insurance policy on April 1st. Her policy includes a zero waiting period for accidental injuries.

On April 5th, Riya unfortunately has a minor accident and requires emergency medical treatment. Since her policy has a zero waiting period, she can immediately file a claim for the treatment expenses.

Riya submits her claim to the insurance company and receives reimbursement for her medical bills according to the policy terms.

This is how it works!

A zero waiting period health insurance plan is generally a good idea as it offers immediate coverage for pre-existing diseases, which is a significant advantage.

However, these plans often come with higher premiums, so it's essential to weigh the benefits against the cost. If you have pre-existing conditions or a family history of serious illnesses, a zero waiting period plan might be a worthwhile investment. 

But, it might not be the most cost-effective choice if you buy it at an early age. Since you're young and likely have fewer health concerns, the chances of needing immediate coverage for pre-existing conditions are lower.

Below are the reasons why you should check the waiting period before finalizing a health insurance policy.

• Understanding Coverage Availability

Knowing the waiting periods helps you understand when and for which conditions you can start claiming benefits. By reviewing these periods, you can determine whether the policy meets your immediate and long-term healthcare needs.

• Preventing Claim Rejection

Understanding waiting periods helps prevent claim rejections due to non-compliance with policy terms. If you file a claim for a treatment or condition that falls within the waiting period, it may be rejected by the insurance company.

• Assessing Policy Suitability as per Health Conditions

Ensuring that the policy’s waiting periods align with your current and anticipated health conditions. If you have specific health conditions or anticipate needing certain treatments, knowing the waiting periods for those conditions helps in selecting a policy that covers these needs within a reasonable timeframe. 

For example, if you have a chronic condition and require regular treatment, choosing a policy with a shorter waiting period for pre-existing conditions will provide better alignment with your ongoing healthcare needs.

• Evaluating Policy Value

Reviewing waiting periods helps assess the overall value and suitability of the policy. Policies with long waiting periods might offer lower premiums but could be less valuable if you need immediate coverage.

The restrictions on the waiting period can be modified with some covers that usually come with an additional cost. However, these modifications depend largely on the insurance provider. Hence, you must check with your insurer for complete details. Below are the ways you can reduce the waiting period for your health insurance policy.

• Opting for a Policy with a Waiting Period Waiver

A waiting period waiver is often an add-on or a special feature within a health insurance policy that can reduce or completely remove waiting periods for certain types of coverage. For example, some insurers provide a PED waiting period waiver that reduces the waiting period for pre-existing diseases from 4 years to 2 years.

• Choosing a Top-Up Plan

Some insurers offer top-up plans or riders that can provide additional coverage with reduced waiting periods. These plans can be added to your existing policy for enhanced coverage.

• Negotiating with the Insurer

In some cases, you can negotiate with the insurer to adjust waiting periods, especially if you have a good health history or are a long-term customer.

• Pre-existing Condition Exclusions

Suppose you have a specific pre-existing condition that is not covered by standard policies. In that case, some insurers offer specialized plans with reduced waiting periods for such conditions, though these may come at a higher cost.

• Opting for Co-payment

Co-payment also reduces waiting periods by sharing treatment costs between you and the insurer, which mitigates the insurer’s risk and can lead to more immediate coverage options. This trade-off often results in shorter waiting periods for benefits.

The survival period in health insurance is the minimum duration an insured must survive after being diagnosed with a covered critical illness to be eligible to receive insurance benefits. This period ensures that the insured survives a certain length of time post-diagnosis, which is essential for making a claim on critical illness policies.

This period can last anywhere between 14 to 90 days, based on the illness and the insurer.

Only after this period can you get the lump sum amount from your insurer, as mentioned in the critical illness cover. This period is calculated based on the first diagnosis of the critical illness and is in addition to the regular waiting period.

Example: If a health insurance policy for critical illnesses has a survival period of 30 days, the policyholder must live for at least 30 days after being diagnosed with a critical illness like cancer before they can claim the benefits.

• Health insurance policies typically include a waiting period for pre-existing conditions, which is usually 2 to 4 years.
• Most health insurance policies have an initial waiting period of 30 days from the date of policy commencement.
• If an individual is diagnosed with a disease for the first time during the waiting period, this condition will not be considered a pre-existing disease. Consequently, the policy will provide coverage for this ailment.
• When transferring from one insurer to another (portability), the waiting period for pre-existing conditions may be carried over from the old policy.
• Waiting periods are generally reset with new policies or renewals unless otherwise specified.
• Insurers are required to clearly disclose waiting periods in the policy document and during the sales process.

Disclaimer: This information is based on general guidelines and standards set by the Insurance Regulatory and Development Authority of India (IRDAI). Always check the specific details of your health insurance plan to understand its waiting period, survival period, and coverage.