What Is a Pre-Existing Disease (PED) in Health Insurance
A pre-existing disease (PED) in health insurance is any sickness, medical condition, or health complication that the insured individual has been diagnosed with before purchasing the health insurance policy.They may involve chronic lifestyle diseases, chronic illnesses, and persistent health problems that need constant medication or monitoring.
Pre-existing diseases are relevant since they determine the coverage of policy, waiting periods, calculation of premiums and the eligibility of claims.This information is used by the health insurers as they want to know the health risk of the individual to cover them accordingly.
In India, IRDAI determines a pre-existing condition as an ailment, disease, injury or condition diagnosed or treated within 48 months before issuing a policy of health insurance. This means any treatment received during the last four years must be disclosed to the insurer.
For parents and senior citizens, pre-existing diseases are common. Conditions like diabetes, hypertension, thyroid disorders, arthritis, asthma, and heart-related issues often fall into the PED category. Understanding how health insurance treats these conditions is crucial to ensuring smooth coverage and claim settlement.
In 2020, the Insurance Regulatory and Development Authority of India (IRDAI) updated the definition of a pre-existing illness. The circular defined a pre-existing illness as a medical condition, sickness, disease, or injury that an insured person has been diagnosed with before purchasing a health insurance policy.
Keeping this circular in mind, health insurance providers started offering health insurance plans for people (especially senior citizens) with pre-existing diseases to provide comprehensive coverage for various medical conditions .
Insuring parents with PED can lead to higher premiums as there is risk involved. It can also lead to limited coverage, with some insurers not offering any coverage for PED.
Waiting periods are a common feature of health insurance plans. Insurers may require a waiting period of up to four years for coverage of pre-existing diseases . Additionally, some insurers may have exclusions, such as no coverage for treatments related to pre-existing conditions.
The options available for health insurance plans for parents with pre-existing diseases are limited. In addition, the insurance providers that do offer such plans may have a limited coverage range or high premiums.
Health insurance plans for parents with PEDs offer comprehensive coverage for treating such conditions.
Most health insurance plans offer cashless hospitalisation and inpatient treatment, which makes it easier for senior citizens to get the required medical assistance.
Health insurance plans also provide coverage for Outpatient Department (OPD) consultations and diagnostic tests, making it easier for parents to manage their pre-existing conditions.
Some health insurance plans come with additional benefits and services, such as health check-ups and healthcare services provided in the comfort of your home.
Standalone health insurance plans are designed specifically for senior citizens and offer coverage for PEDs from day one.
These provide coverage for the entire family, including parents with PEDs.
Health insurance plans for senior citizens are designed specifically for senior citizens and provide coverage for PEDs.
Selecting the perfect health insurance plan that caters to your parents’ needs can be daunting. However, when selecting a plan, it is important to assess your parents’ healthcare needs along with your budget. It is also essential to compare plans and their benefits , and consider the insurer's reputation and financial strength.
The waiting period is the first thing to consider when you select a health insurance scheme that covers pre-existing diseases. This is the mandatory time you must wait before PED-related claims become admissible. Depending on the type of insurer and plan, the waiting period can take between 1 and 4 years.
For example, if your parent has diabetes and needs regular hospitalisation or procedures like angiography or insulin-related complications, selecting a plan with a shorter waiting period can save you significant medical expenses.
Some insurance providers apply sub-limits on PED coverage. These may include:
Understanding these limits helps you estimate how much financial support your policy can genuinely offer during medical emergencies.
Cashless hospitalisation is one of the most valuable benefits of modern health insurance. When you are buying a PED-inclusive health plan for your parents, checking the network hospital list is extremely important.
Before purchasing a policy, compare:
Co-payment terms frequently exist in health insurance schemes of persons with pre-existing illnesses.The proportion of the claim amount that you are required to pay, as the insurance company covers the rest of the amount, is known as a co-pay.As an example, when your policy contains a 20% co-pay and your gross claim is 100,000, you will pay 20,000, and the insurance company will cover 80,000.
When buying PED coverage, you must also understand the renewal features, such as:
Continuous renewal is essential to keep PED coverage active. If the policy lapses and you renew it after the grace period, the PED waiting period may restart. That's why choosing a policy with simple renewal terms is highly beneficial.
For customers in the 40+ or 50+ age group, most insurers recommend a pre-policy medical check-up. This is especially true for people with known or suspected pre-existing diseases.
Many insurers offer free medical check-ups, especially for higher sum insured plans. Some even reimburse the cost during policy issuance.
During the check-up, the following tests are usually performed:
Being honest during the proposal stage is crucial. Non-disclosure of pre-existing diseases may result in claim rejection later. A medical test ensures both you and the insurer start the policy on clear, transparent terms.
Understanding pre-existing diseases and how they are treated under health insurance is extremely important- especially when choosing a plan for your parents or senior family members. With rising healthcare costs, having a policy that provides strong PED coverage not only offers financial security but also ensures timely access to quality medical treatment.
By comparing waiting periods, reviewing co-pay clauses, checking cashless hospital networks, and completing pre-policy medical exams, you can choose a health plan that delivers comprehensive protection. Proper PED coverage helps families stay prepared for unexpected medical situations while maintaining long-term financial stability.
A pre-existing disease is any health condition diagnosed or treated within 48 months before purchasing a health insurance policy. This includes chronic diseases like diabetes, hypertension, thyroid disorders, asthma, and heart ailments.
Most insurers cover lifestyle diseases such as diabetes, blood pressure, cholesterol issues, thyroid disorders, arthritis, asthma, COPD, and early-stage heart-related problems after the waiting period.
Premiums depend on factors like age, medical history, type and severity of the PED, lifestyle habits, coverage amount, and plan benefits. Policies with shorter waiting periods or higher sum insured may have higher premiums.
Waiting periods typically range from 1 to 4 years. Some senior citizen plans or special health covers offer reduced waiting periods for an additional premium.
Yes, you can port to another insurer. The waiting period already served should be credited by the new insurer in case the policy is ported without a break, and the PEDs were disclosed properly in the previous policy.
Pre-existing diseases are covered by most of the insurance companies, particularly the specialised health insurance companies, with waiting periods and policy terms.Plans differ in terms of coverage; thus, it is necessary to compare features.
Plans with shorter PED waiting times, less co-payment, strong cashless network hospitals, and lifetime renewability will be the best.The best option will be based on personal health requirements and age.
Yes, every insurer that is under IRDAI provides PED coverage, yet the terms, period, and limits of cover vary.Certain conditions can have certain sub-limits or extra co-pays.
