Buying health insurance in the face of pre-existing conditions.

The burden of illnesses like heart-related ailments, diabetes, respiratory conditions, etc., has increased significantly over the last two decades. Look at any household and chances are that you would find a member suffering from one or more of these conditions. Even the numbers indicate the rising instances of illnesses. According to a study conducted in 2015 by the ICMR, Health Metrics and Evaluation (IHME) and the Public Health Foundation of India (PHFI) in collaboration with the Ministry of Health, these diseases had jumped from 30% in 1990 to 55% in 20161. In 2020, diabetes assumed epidemic proportions as 77 million Indians were reported to be suffering from the disease2.

Numbers don’t lie, do they?

With diseases and ailments becoming so common, many individuals suffer from one or the other form of pre-existing conditions. Does a health insurance plan provide coverage in such a case?

There are families where the different family members have various pre-existing ailments, such as heart problems, diabetes, etc. What is the best option for them? A regular indemnity plan or a disease-specific individual health plan? Let’s find out.

Health insurance in case of pre-existing conditions:

Most indemnity health insurance plans allow coverage even if the insured suffers from a pre-existing illness. Coverage for the pre-existing condition is usually excluded for a few years. This period is the pre-existing waiting period, and it usually ranges from 12 months to 48 months. So, if you or someone in your family has a pre-existing disorder, opting for such a cover could be an option.

However, before you opt for such a plan, keep the following points in mind:

  1. Waiting period –
    The health insurance plans from different health insurance companies seldom have identical clauses. This is why the waiting period clause is also different. You need to look for a plan that has a low waiting period for pre-existing diseases. This will help you to get the maximum coverage in the least amount of time.
  2. Exclusions –
    If the concerned family member (which can be you or a loved one) has a severe pre-existing illness, he or she may not be covered under the family floater health plan. This is why you need to read the list of exclusions very carefully before you sign on the dotted line. In such a case, you can opt for an individual health plan for him while the rest of the family could be a part of a family floater plan.
  3. Undertaking –
    If you have a pre-existing ailment, the insurance provider will give you an undertaking, based on which you can decide on the coverage. Read it carefully and agree upon it, only if you feel the coverage is sufficient and comprehensive. This is a declaration of good health and needs to be filled up in good faith after disclosing all relevant information about the people insured!

An alternative – disease-specific health plans

There are disease-specific health insurance plans too. These plans are designed to cater to the health insurance needs of individuals suffering from a particular disease. Usually, disease-specific health insurance plans are allowed for the following types of illnesses –

●  Heart conditions

●  Diabetes

●  Cancer

Some of the salient features of these plans include the following –

  1. There is a short waiting period of a year or two after which coverage for the illness is allowed
  2. Some plans, like diabetes and heart-related plans, are designed specifically for individuals suffering from such illnesses
  3. All medical complications resulting from the existing illness are covered
  4. Pre-entrance health check-ups might or might not be needed depending on the insurance company
  5. Besides  the specific illnesses, such plans also allow coverage for normal hospitalisation
  6. Premiums are affordable and can be paid in instalments

Go over the terms and conditions associated with each plan. If you feel the individual policy will offer better coverage, get this type of plan to keep yourself or your loved ones wholesomely covered.

Disease-specific health plans v/s indemnity oriented comprehensive plans

When comparing to see which solution is better, you can consider the following two factors:

  1. The coverage offered in each
  2. The premium payable for each

Firstly, compare the coverage benefits. Suppose the standard indemnity policy allows a broad scope of coverage with minimal restrictions. In that case, you can opt for a regular indemnity plan. This is especially true if the insured person is treading on the borderline of illness, with minor conditions.

However, if the indemnity plan limits the coverage scope, you can opt for disease-specific health plans as well. A disease-specific plan is always good for severe conditions. In such a case, you need to opt for individual health plans only.

Secondly, tally the premium of the indemnity plan with the individual disease-specific cover. However, the premium should not be the only factor upon which you base your decision. The coverage is necessary too. Ideally, it would help if you looked at whichever plan offers the most comprehensive coverage and then choose accordingly. Even if the premium is higher, the coverage will outweigh the additional premium, considering the rising healthcare costs.

This is why you should opt for the plan offering the maximum coverage while at the same time, ensure the affordability factor as well.

Actionable Points:

While buying a health plan with pre-existing conditions, here are some points that you can keep in mind –

  1. Try and opt for the maximum possible sum insured, even if you do not feel the need for it now. An angioplasty costs about Rs.1 lakh to Rs.3.5 lakhs, while a bypass costs Rs.2 lakhs and above3. Having optimal coverage is, therefore, essential.
  2. Look at the waiting period. Try and opt for a lower waiting period. Some plans allow you to buy back the waiting period by paying an additional premium. If your pockets permit, go for the buy-back feature and reduce the waiting period.
  3. Keep a lookout for the sub-limits or limits imposed. Try and pick a plan with the maximum coverage.
  4. Pre-entrance medical check-ups would be mandatory under most plans. Be prepared to undergo the check-up.
  5. The premiums would be on the higher side, given the increased health risk.
  6. Do not include your parents under your floater coverage if they have pre-existing conditions. This would drive up your premium and also impose coverage restrictions. Instead, opt for a separate policy for your parents suffering from pre-existing conditions.

In conclusion

Health insurance aims to cover each and every person in a well-rounded and comprehensive manner. You need to do your research and see which plan is best suited for yourself and your loved ones. If your family members have several pre-existing disorders and you feel a family floater plan won’t be of the best use, opt for a dedicated individual health cover that would take care of all their medical requirements. You need to assess your family’s medical insurance requirements and get the ideal coverage accordingly.



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