Here's how one can deal with a pre-existing disease clause in health insurance policy

A health insurance policy is bought to cover oneself from unforeseen contingencies. It keeps our savings protected which we have accumulated over many years of hard work. But it often happens that health insurance claims get rejected. From missing documents to late renewal reasons for rejection could be many. However, one of the most common reasons is the non-disclosure of pre-existing illnesses. 

A pre-existing disease is a medical condition that exists at the time of buying a policy. For instance: diabetes, heart disease, and hypertension are considered pre-existing diseases. It is important to note that pre-existing illnesses are not covered from day one in a health insurance policy. The regulator has prescribed the maximum waiting period of four years for pre-existing illnesses and after four years, insurers are bound to cover all pre-existing illnesses. There are, however, many insurers that offer policies with a shorter waiting period of two years. 

To avoid last-minute hassles it is always good to disclose all health-related problems at the time of buying the policy, as diseases arising out of earlier complications, such as obesity and hypertension, can also be considered pre-existing illnesses which will subsequently not get covered in your health plan. 

But at times it happens that claims get rejected even if the person was not suffering from any disease at the time of buying the policy. What should one do in such situations? What if the policyholder was not having any pre-existing illness at the time of buying the policy? But later that person’s claim got rejected on the grounds of hypertension as a pre-existing condition. 

Dr Bhabatosh Mishra, Director Underwriting - Products and Claims, Niva Bupa Health Insurance, says, “Pre-existing disease is a term whose definition has been standardized by the regulator. Definition apart, the fundamental and most important point in the case highlighted is the fact that the concerned customer didn't have Hypertension at the point of purchasing the policy or earlier. In that case, it cannot be termed as a pre-existing condition or non-disclosure of a condition.”

Mishra, in such cases suggests that one needs to write to the grievance cell of the insurance company with all details and documents. “If the decision is not to your satisfaction, one can approach the insurance ombudsman for redressal of concern,” he says.

“Consumers should read the policy document carefully and make full and accurate disclosure of medical history, family risk factors and existing medical conditions, past accidents, injuries, acute incidents, and chronic problems at the time of policy purchase itself. Consumers should always keep in mind that providing complete and correct information, understanding all the policy terms and conditions, added with taking the route of digitally enabled insurance advisors are the best way to buy any health insurance policy,” explains Indraneel Chatterjee, co-founder, RenewBuy.