Health insurance is a crucial safety net, but for individuals with pre-existing conditions, navigating coverage can be complex. A pre-existing condition—any illness or health issue diagnosed before purchasing a policy—often impacts how insurers assess risk, determine premiums, and impose waiting periods.
To address customer confusion, the Insurance Regulatory and Development Authority of India (IRDAI) has introduced standardized rules to enhance transparency. The waiting period for health insurance coverage related to pre-existing conditions and specific diseases is now capped at a maximum of 36 months. This means that a policyholder who maintains a continuous health insurance policy for 36 months will become eligible for coverage of pre-existing diseases.
Additionally, “a new rule states that after continuously holding a policy for 5 years, insurers cannot deny a claim or renewal based on unintentional non-disclosure for a pre-existing condition. Therefore, the only impact pre-existing conditions will have on health insurance coverage is the waiting period for specific diseases. During this waiting period, the disease’s costs and associated conditions will not be covered. However, all other coverages will still be in effect,” informs Bhaskar Nerurkar, Head- Health Administration Team, Bajaj Allianz General Insurance.
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According to insurers, insurance is based on sound actuarial principles of understanding the associated risk and pricing it adequately to cover the cost of an incident. If the risk is high, the premium is high and vice versa.
“With a pre-existing condition, the health risk of an individual is higher than someone who is leading a disease-free life. Insurers assess the health of an individual at the time of policy purchase. If the customer does not carry any ailment, then the buying journey is seamless with instant policy issuance. On the other hand, someone who has a medical condition is asked to undergo a health assessment based on which the insurer might load the premium to compensate for the higher health risk or offer a restricted cover,” says Nirmal Gupta, Head – Health Claims & Underwriting, Magma General Insurance Limited.
For example, common lifestyle conditions like diabetes might come with a loading on the premium, while a more advanced stage of illness like chronic kidney disease could be offered with coverage restrictions. While some severe conditions may make it harder to get a policy,
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