Any disease identified within three months of purchasing a health insurance policy is now included in the IRDAI’s revised definition of pre-existing diseases. #
The Insurance Regulatory and Development Authority of India (IRDAI) published guidelines on standardisation in health insurance on September 27, 2019, including this modification. Products filed after October 1, 2019, will be subject to these standards. The new regulations will take effect for health contracts on October 1, 2020. #
What Is A Disease That Already Exists?
Pre-existing diseases (PEDs) are conditions, illnesses, or injuries present when you purchase a health insurance policy and are typically not covered by the procedure for the first waiting period. For these PEDs, a maximum 4-year waiting period is allowed.*
According to IRDAI regulations, “It is a condition, ailment, injury, or related condition(s) for which the policyholder had signs or symptoms, was diagnosed, and received treatment for any of the following in the period of 48 months prior to the first policy that was given by the insurer and renewed immediately after that.”
Modification Of The PED Definition
The IRDAI circular states that a condition will be considered PED if any symptoms or signs are present and have led to a diagnosis of an illness or medical condition within three months of the policy’s issuance. This clause supplements the existing definition of PED. #
The guidelines outlined in the September 27 2019 circular include the PED expansion.
Suppose a person has been complaining of dark shadows in their vision for a year and is diagnosed with retinal detachment within three months of purchasing an insurance policy. In that case, that disease will not be covered because it will be viewed as a PED. However, the disease will get health insurance coverage if the retinal detachment is discovered six months after purchasing the insurance policy. A disease can only be labelled as a PED condition after three months if there is unambiguous evidence that it was previously diagnosed. The illness cannot be categorised as PED if it is undiagnosed. *
As a result, the definition of PED in the guidelines published on September 27, 2019, states that a disease will be considered PED when any symptom or disease has manifested in a diagnostic illness or medical condition within three months of the policy’s issuance.*
As a result of the insurer’s suspicion that the illness for which the claim was filed was a PED, there have occasionally been disagreements between the insurer and a policyholder who filed a lawsuit within a few months of purchasing the policy.
The new circular of modification guidelines on standardisation in health insurance will bring some changes. This will reduce fraud early claims coming because there was no waiting period after the policy issuance. Anyone who becomes ill within three months of getting insured may have their claims denied under the new provision (the amended definition of PED), which is not in the policyholder’s favour.
# Visit the official website of IRDAI for further details.
*Standard T&C Apply.
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