Pre-existing ailments are not covered for specified periods

Before policy issuance, insurers typically do a medical underwriting based on the person’s age, previous medical history and quantum of sum assured


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I am 31 years old and underwent laparoscopy for kidney stone removal in 2011. A health insurance company said I won’t be covered for any kidney-related procedure for the next two years and my premium will be higher than for a normal person (without medical history). What should I do?

—Roshni Das

The feedback you have received is in line with market practice. Insurers do not cover pre-existing ailments for specified periods. For a person of your age, pre-existing waiting period varies from two to four years. During this period, treatment for conditions that existed before the policy issuance is not covered. The two-year waiting period mentioned by you refers to this pre-existing disease waiting period.

Before policy issuance, insurers typically do a medical underwriting based on the person’s age, previous medical history and quantum of sum assured. After their assessment, they may adopt any of the following three approaches for a non-standard proposal: decline the proposal completely; offer to issue policy subject to some permanent exclusions; or issue the policy with a loading for adverse risk. You have described the third scenario above. The rationale for the above is that people with a medical history have a higher likelihood to claim due to a relapse or another ailment.

Do all health insurances that cover expenses for hospitalisation also cover child delivery-related hospitalisation? Do I have to take some other cover for my wife pregnancy? She is due to deliver in May? I have a health insurance of Rs. 5 lakh.

—Karan Kalia

All health insurance policies do not automatically cover maternity-related expenses. In fact, unless mentioned otherwise, maternity is a standard exclusion in most policies. Policies that offer maternity coverage have specific waiting period. It varies from nine months to three years. So, if the woman has already conceived, then the maternity cannot be covered under a standard individual plan.

Once an ‘ailment’ is identified or has occurred, fresh insurance cannot be issued to cover it. Also, plans that offer maternity benefit typically have a sub-limit for maternity. For instance, they may say that maternity expenses will be paid up to a maximum of Rs.50,000 within the overall sum insured.

You should also note that most policies do not cover a new-born baby automatically from date of birth. Most policies exclude coverage for new-born babies until they are 91 days old. So, any ailment immediately after birth is not covered. Also, such diseases are excluded post that as they are classified as pre-existing.

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