Posted by Health insurance is the newest asset that the young generation wants to invest in. As health is the prerequisite of productive life, your investment in health care plans is a conscious choice that will lead you to enjoy several benefits. However, availing of such plans must be dealt with with extreme caution. From submitting the proper paperwork to the knowledge of dispute redressal – an insurance holder must be aware of every involved step.
One such area of careful observance is the ‘pre-existing condition’—a health illness or an injury that you already have before starting a new health care plan. This can include conditions like diabetes, COPD, cancer, and sleep apnea. These pre-existing conditions, if not deliberately studied before, can create a lot of fuss in the plan that nobody would like to encounter.
Here, in this write-up, you will come across an overall understanding of the fuss regarding pre-existing diseases. Let’s check it out.
Why is ‘Pre-existing Condition’ Taken into Account?
The first step in the process through which a health insurer approves a health care plan to a seeker involves the evaluation of medical history to date. As the insurer is taking the big financial responsibility of a lifetime of hospitalization expenses, they will henceforth want to understand your health condition, medical history of any diseases or injuries as correctly as possible – a record of your health and how healthy you have been in taking care of yourself before.
As health insurance companies are for-profit corporations, they are not legally obliged to give anyone a policy. It is actually a deal made based on mutually acceptable terms on both ends of the parties involved. In case the terms do not mutually equate, they can decline the proposal.
Premiums are charged based on the assumption that the person buying the policy is a healthy person with an active lifestyle with no pre-existing conditions; they are able to provide an annual cover close to 30-50 times what you were supposed to pay.
However, if you have an existing health condition or a not-so-good medical history, it indicates a higher likelihood that you will need frequent hospitalization in the future. So, the insurer would need comprehensive information to check whether they can afford to offer you the standard deal and insure your health with the same benefits and at the same price, or in the negative. Thus, pre-existing conditions become the basis of a health care plan automatically.
Consequences of Sharing Wrong Information Regarding Pre-existing Conditions
One must always provide the insurer with accurate, truthful information about all pre-existing conditions. If not done so, it will not be a fair deal, and the insurer ends up making a bad decision. It’s not just the insurer’s problem as your claim can even be denied after such a revealing of facts.
- Denial of the Claim:
In case you are hospitalized for an unrelated disease or an injury, the insurer will be informed about your pre-existing condition from your medical files and reports to hospital receipts and bills. Once an insurer realizes a misrepresentation in the policy, they may decline your health insurance claim even for a disease or injury unrelated to the hidden health condition. They might even cancel your policy altogether, even after you’ve paid premiums on time, for decades.
2. Difficulty in Buying Another Policy Plan:
If the insurer comes to realize about a pre-existing disease when you are being hospitalized several years later, it can be extremely difficult to apply for or buy another policy plan as the costs quoted might be as high as the insurer cannot even guarantee to provide, so you might just not be given any policy at all.
The Waiting Period
As per regulations, the waiting period for pre-existing diseases is defined as a condition, ailment, injury, or disease diagnosed or treated by a doctor 48 months preceding the date the health insurance cover starts.
Insurers usually apply a waiting period of two to four years, depending on the conditions mentioned in their respective policy plans, for such diseases. As per this regulatory definition, any disease that was diagnosed more than 48 months before the insurance policy started or cured cannot be considered a pre-existing disease and hence cannot be excluded under the pre-existing disease clause of the plan.
For instance, if you had an old medical history of having Tuberculosis in your childhood which got cured before you became an adult, and had not undergone any treatment for Tuberculosis in the last 48 months prior to availing the health insurance plan, Tuberculosis would not be considered as a pre-existing disease in this case.
Other Relevant Clauses to be noted:
Insurers most often respond to a health insurance application based on the declarations and severity of your health condition. In the circumstance of chronic sickness, lifestyle disease such as obesity, or consequences of an unhealthy lifestyle like excessive smoking, being reported, the insurer may put additional conditions in your policy which you must analyze before signing.
The Denial clause: Some pre-existing conditions might often be too complex for an insurer to estimate the risks taken on. So, they can make a free call to not insure the individual and decline the proposal altogether without offering a possibility of dispute in this case.
Application of loading: Insurers may apply a loading of usually 10% to 50% on the standard premiums, based on the declarations you provided.
Restrictions: In case of some chronic health conditions, the insurer could impose restrictions such as an additional copay for every claim made.
Precisely Define permanent exclusions: As some pre-existing diseases can have severe effects on the health of a person for a long period of time, insurers are allowed to apply a permanent exclusion for a list of diseases where they were earlier declining coverage altogether. The list includes diseases such as Cancer, Epilepsy, Heart Ailment, Stroke, Liver disease, Pancreas ailments, Bowel Disease, Kidney Disease, Hepatitis B, HIV, and Alzheimer’s, among others.
Therefore, pre-existing conditions must be dealt with seriously when applying for a health insurance plan. If you have them, make sure to take the highest coverage you’re eligible for from the insurer, as getting the same upgrades later could be a challenge for you.