Health Insurance rule change: This 3-month new rule will impact your claims

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Updated: October 21, 2019 11:43:03 AM

The new definition for pre-existing disease will apply to all health insurance products including group covers filed on or after October 1, 2019.

Pre-Existing Disease, health insurance, health insurance claims, irdai, insurersAny medical conditions considered own as pre-existing diseases are covered only after a specific waiting period.

Health Insurance Claims: At the time of buying health insurance, the insurance companies do not provide coverage to ailments or diseases from day one, that the policyholder is already suffering from. Any such medical conditions are known as pre-existing diseases and are covered only after a specific waiting period. As per the current health insurance rules, the insurers need to cover the pre-existing ailments after a waiting period of 48 months, some insurers in some of their plans allows a lower waiting period of 24 or even 36 months.

The Insurance Regulatory and Development Authority of India (IRDAI) has recently brought about a change in the definition of pre-existing diseases in the health insurance plans. “The major change in the definition of Pre-Existing Diseases (PED) is that now even after the issuance of the policy, if the policyholder is diagnosed with any ailment within 3 months of the issuance, then the same ailment or disease will be considered as a PED upon the disclosure of the policyholder.”

As of now, Pre-Existing Disease is defined as, “Any condition, ailment or injury or related condition(s) for which you had signs or symptoms, and / or were diagnosed, and / or received medical advice / treatment within 48 months to prior to the first policy issued by the insurer.”

New rule for Pre-Existing Diseases

As per the new IRDAI rules, effective October 1, 2019, Pre-existing Disease means any condition, ailment, injury or disease:

a) That is/are diagnosed by a physician within 48 months prior to the effective date of the policy issued by the insurer or

b) For which medical advice or treatment was recommended by, or received from, a physician within 48 months prior to the effective date of the policy or its reinstatement.

c) A condition for which any symptoms and or signs if presented and have resulted within three months of the issuance of the policy in a diagnostic illness or medical condition.

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The new definition will apply to all health insurance products including group covers filed on or after October 1, 2019.

But, what if a policyholder hides medical information and does not disclose the existence of pre-existing diseases at the time of buying? “If the policyholder does not disclose the PED at the time of Policy buying or even after the 3 months of the issuance, their policy can get rejected providing they have filed the claim for hospitalization because of the same ailment. This is only until a maximum period of 8 years of a policy. After 8 years, a claim cannot be rejected.”

A proper and honest declaration is a part of the application form signed by the policyholder. Hiding information may result in a repudiation of the claim at a later stage even if it is a PED. If you are porting your health insurance policy from one insurer to another, make sure the benefit of the waiting period of PED ( the residual time period) is also carried forward on to the new insurer.

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