What is Pre Existing Condition in Health Insurance?

What is Pre Existing Condition in Health Insurance

Every health insurance policy has a pre-existing condition clause. Purchasing medical insurance might be challenging for those who have had pre-existing health conditions for a few years.

Health insurance is becoming a need and a necessary financial safety net in case of a medical emergency.

According to statistics, 514 million people in India were covered in health insurance plans for the financial year 2021.

It’s important to grasp a few things, including how insurance companies manage their plans for insurers with pre-existing disease and what you have to know about pre-existing condition coverage for health insurance.

This article will help you the best insurance company if you or your loved one have a pre-existing disease.

What is a Pre-Existing Condition?

A pre-existing condition is a disease or health issue an insured person had before buying health insurance.

According to India’s Insurance Regulatory and Development Authority (IRDAI), an illness is considered pre-existing if the insured person received a diagnosis of it up to 48 months before purchasing the policy.

What are the Examples of Pre-Existing Health Conditions?

All chronic health concerns, including high blood pressure, thyroid problems, cancer, diabetes, asthma, etc., are considered pre-existing conditions.

A pregnancy that occurs before enrolment is also recognized as pre-existing and chronic. Other less severe ailments like acne, anxiety, and sleep problems might also be considered.

Key Takeaways:

  • An illness that existed before you applied for health or life insurance is known as a pre-existing condition.
  • Illnesses like diabetes, cancer, and heart problems are examples of conditions.
  • The Affordable Care Act (ACA) prohibits health insurance providers from denying coverage or raising premiums for those with pre-existing conditions.
  • Some companies will provide you with life insurance if you suffer from a pre-existing condition, but your premiums will go up while your death benefits will go down.

Recommendations for Buying Health Insurance with a Pre-Existing Condition?

People with pre-existing health problems need to undergo a pre-policy medical examination to purchase medical insurance. The insurer’s premium will be based on the medical assessment results, age, and sum assured.

Pre-acceptance medical tests could result in the insurer declining to sell the insurance or reducing the policy coverage.

I’m sure you’re wondering how to get around this problem.

Here are a few tips to help you choose the right health insurance plan, even if you suffer from a pre-existing condition:

1. Pre-Existing Disease Coverage is Offered After 48 Months:

It might be too expensive along with a waiting period while purchasing health insurance with a pre-existing medical condition.

According to the most recent IRDAI standards, the health insurance company can only declare a pre-existing condition if the disease has been diagnosed or treated within 48 months (4 years).

It’s not mandated to wait for 4 years, as you can’t predict the disease will invade your body again. Better, check for insurance companies with lesser waiting periods for pre-existing diseases.

2. Never Keep a Pre-Existing Condition a Secret:

Don’t hide any pre-existing medical conditions from the insurance company when purchasing insurance coverage.

Hiding information or giving the insurance company false information will put you in trouble in times of emergency.

This is important because the insurer may deny your health insurance claim if your pre-existing condition is revealed when you receive treatment.

Just think of an example, you buy health insurance at age 30, by cloaking a disease that was treated within 4 years. Unfortunately, the disease attacks you at the age of 60 or 70.

While claiming the insurance, your discharge summary would hold the complete history of the disease.

This could inform the insurance company that the disease has already been present, and lead to a high chance of claim rejection.

3. Every Medical Appointment Does Not Be Considered a Pre-Existing Condition:

Health insurance providers will only consider pre-existing conditions that may have a long-term impact on you when calculating your premiums.

So, do not worry if you frequently get the flu, a cough, a cold, or a fever.

4. Pre-existing Conditions Have a Waiting Period:

A waiting period refers to the time when your insurance provider won’t pay out on a claim for a condition you already have.

Your insurance provider will reject any claim made during this time to treat a pre-existing condition.

The waiting period indicates that you cannot use your health insurance immediately (only for pre-existing conditions) after purchasing it.

An average waiting period for pre-existing conditions lasts between three and four years.

Different health insurance companies have different waiting periods for pre-existing conditions.

5. Waiting Period Can Be Waived-Off in Some Cases:

Some insurance companies may waive off the waiting period if you pay an extra premium. In this case, the waiting period’s length is either shortened or eliminated.

However, depending on your condition’s severity, the insurance provider makes a decision.

The waive-off facility may not work under two conditions,

  1. The stage of the disease is severe
  2. Advanced Age

It is best to double-check this before getting health insurance.

6. Health Insurance Terms and Conditions Might Differ:

The screening process, waiting period, list of pre-existing conditions, and so on can vary depending on the health insurance policy, kind of coverage, riders, insurance company, etc.

Most insurance companies would require you to get a medical check before they would consider offering you a policy. Some insurers might also take your age and medical records into account.

Therefore, before choosing a medical insurance plan, you should review the purchasing process and the terms and conditions.

7. Avoid Pre-Existing Disease Coverage Plans with Co-Payment Clauses:

Some insurance companies may include a co-payment provision for pre-existing illness coverage.

According to this provision, you will be required to contribute a portion of the claim amount at claim settlement, and the insurer will cover the remaining balance.

However, not every health insurance plan has a co-payment provision for covering pre-existing conditions.

So, purchase a health insurance policy without a co-payment provision.


Health insurance plays a vital role in financial planning and securing the future for everyone. A pre-existing condition does not prevent you from getting health insurance coverage, and every health insurance plan is unique in some way.

Preexisting conditions and the waiting period’s terms and circumstances must be reviewed before acquiring a plan.

Buying family health insurance that covers pre-existing conditions may be beneficial if you take care of your elderly parents