The Economic Times
English EditionEnglish Editionहिन्दी
| E-Paper
Search
+

    IRDAI amends definition of pre-existing diseases, a move that can reduce insurance claim rejection

    Synopsis

    Last year in September, the regulator had modified the definition of pre-existing diseases (PEDs) to include certain illnesses if diagnosed within three months after purchasing the health insurance policy.

    Getty Images
    The definition of PED is now clear reducing any ambiguity.
    ET Calculator Banner
    The insurance regulator has amended the definition of pre-existing diseases, a move which could lead to a reduction in the claim rejection rates in health insurance. The Insurance Regulatory and Development Authority of India (IRDAI), through a circular dated February 10, 2020, has deleted 'the additional/modified clause' in its current definition of pre-existing diseases.

    Last year in September, the regulator had modified the definition of pre-existing diseases (PEDs) to include certain illnesses if diagnosed within three months after purchasing the health insurance policy. This definition was included in the guidelines on standardisation in health insurance released by IRDAI on September 27, 2019.

    However, through its circular issued today, the regulator has now deleted this clause. Thus, as per the new definition, no such disease will be treated as PED even if diagnosed within three months, or later, after buying the health insurance policy.

    Naval Goel, CEO, PolicyX.com said, "This is a welcome move for policyholders. Sometimes an insured may develop a condition within 3 months of buying a policy. Insurers earlier could reject such claims in policies in certain cases where they deemed the condition to be defined as a PED. Now, the definition of PED is absolutely clear reducing any ambiguity. This move will definitely reduce the claim rejection rates in health insurance."

    Also read: Certain illnesses in 1st 3 months of health insurance policy to be treated as pre-existing disease

    All insurers and third-party administrators (TPAs), wherever applicable, are advised to make changes and ensure compliance with immediate effect, IRDAI stated in its circular.

    As per IRDAI, the change in the Definition of Pre-Existing Disease (not applicable for Overseas Travel insurance) is mentioned below
    Existing New
    Pre-existing Disease means any condition, ailment, injury or disease:Pre-existing Disease means any condition, ailment, injury or disease:
    a) That is/are diagnosed by a physician within 48 months prior to the effective date of the policy issued by the insurer ora) That is/are diagnosed by a physician within 48 months prior to the effective date of the policy issued by the insurer or
    b) For which medical advice or treatment was recommended by, or received from, a physician within 48 months prior to the effective date of the policy or its reinstatementb) For which medical advice or treatment was recommended by, or received from, a physician within 48 months prior to the effective date of the policy or its reinstatement
    c) A condition for which any symptoms and or signs if presented and have resulted within three months of the issuance of the Policy in a diagnostic illness or
    medical condition.
    Deleted
    (Life insurers may define
    norms for applicability of
    PED at Reinstatement)
    (Life insurers may define
    norms for applicability of
    PED at Reinstatement)
    Source: IRDAI

    What is a pre-existing disease?
    A pre-existing disease is a condition, ailment or injury that already exists at the time you buy a health insurance policy and these PEDs are generally excluded from the policy coverage for an initial waiting period. The maximum waiting period on such PEDs is four years.
    Download The Economic Times News App to get Daily Market Updates & Live Business News.

    6 Comments on this Story

    khadim kapadia158 days ago
    My daughter is suffering from schizophernia since 2014. In 2016 I was approached by an agent of an insurance company. When I told him about her condition he said that people with that disease will not be covered by any Mediclaim policy. Alternately he told me that I could not disclose this fact and also not place any bills for treatment/medicines of this disease. I assurd him that I would do so.So, from 2016 till 2020 my daughter did not place any bills for this disease. In 2020 she was admitted for Appendicities. In the discharge form the hospital had written her past history/disease as Schizophernia and acting on this the insurer has refused to reimburse/renew her policy, stating that due to non- disclosure of the pre-existing health condition, we regret to inform that we are unable to provide with the health cover in policy and renew the policy further.My point is that the entire hospitalisation/treatment was for Appendicites and not for Schizophernia. I want to know what steps I could take for reimbursement/renewal.
    Swapnil346 days ago
    let the insurance companies and IRDA die it's death.. as the tax benefit is removed, the Insurance companies will see a hot on their margins and new customers.. earlier they used to lure people into this telling them tax benefits and then the rest of terms and conditions.. now that selling point is being taken away from them.. it will be interesting to see how it impacts their business now.
    Ivanna Santino347 days ago
    I saw the fear in my husband and children's eyes when I told them about my condition then they start to find solution on their own to help my condition.I am an 59 now who was diagnose COPD emphysema which I know was from my years of smoking. I started smoking in school when smoking was socially acceptable. I remember when smoking was permitted in hospitals. It was not known then how dangerous cigarettes were for us, and it seemed everybody smoked but i was able to get rid of my COPD lung condition through the help of total cure herbal foundation my husband bought, totalcureherbsfoundation com has the right herbal formula to help you get rid and repair any lung conditions and cure you totally with their natural organic herbs,it class products at affordable prices. Purchase these medicines and get the generic medicines delivered in USA, UK & Australia,I wish anybody who starts smoking at a young age would realize what will eventually happen to their bodies if they continue that vile habit throughout their life.
    The Economic Times