No insurance coverage for first three months of treatment

K. ARAVIND

Pre-existing illnesses are not covered for a specified period after taking out a health insurance policy. The Insurance Regulatory and Development Authority (IRDA) has made some amendments to the existing definition of pre-existing diseases. Illnesses or injuries at the time of taking out a health insurance policy are considered pre-existing illnesses. Usually such diseases are not covered till four years after taking the policy.

The IRDA guidelines state that any illness or injury that the policyholder has been diagnosed with or treated for during the first 48 months prior to taking out the policy will be treated as pre-existing. The IRDA’s new amendment states that even if a patient is diagnosed with an illness within three months of taking out the policy, it will still be considered a pre-existing condition.

For example, if you experience vision problems six months before taking out a policy and is diagnosed with cataracts within three months of taking the policy, you will be considered a pre-existing condition and will not be covered for a fixed period of time (up to a maximum of four years). At the same time, if the disease is diagnosed six months after taking out the policy, it will be covered. If a disease is to be classified as pre-existing after three months, there must be authentic evidence that it was diagnosed earlier. If not diagnosed, it cannot be considered a pre-existing disease.

In the case of claims made within a few months of taking out the policy, the insurance company often raises doubts and disputes as to whether the disease is pre-existing. The new amendment will help to avoid such ambiguities. According to the amendment, the claim will be denied if the patient seeks treatment for any disease within three months after taking the policy.

Pre-existing illnesses may be denied coverage for such illnesses throughout the term of the policy unless disclosed at the time of taking out the policy. Such coverage may be denied even if the diagnosis is made through a medical examination within three months of taking out the policy. This is done in the name of non-disclosure of mandatory disclosures.