A clause that classified pre-existing diseases to include those that one contracts within the first three months of the policy has been deleted.

Insurance regulator revises definition of pre-existing diseases for policyholders
Money Insurance Tuesday, February 11, 2020 - 18:37

The Insurance Regulatory Authority of India (IRDAI) has made changes to the health insurance policy terms related to pre-existing diseases. 

A common clause in insurance policies is that they will not cover pre-existing diseases, and the policy holders struggle to press their claims. A new circular issued by IRDAI has deleted ‘the additional/modified clause’ in the definition of pre-existing diseases as it appears currently. The basic definition of a pre-existing disease is where the policy holder had availed or was recommended by a physician to avail treatment for a condition within 48 months before the policy is issued or reinstated. 

The issue relates to what is defined as a pre-existing disease. Some chronic ailments are already on the list. These include diabetes, COPD, cancer, lupus, epilepsy, depression, anxiety, sleep apnea, etc. A change was made last year, where a 3-month window was included.  

"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," the clause earlier read.  This meant that if a person takes a policy and within three months since the start of the policy is detected with a disease, it will not be covered for claims. With this latest amendment, IRDAI has deleted this clause, retaining only the 48 month clause. 

For now, a pre-existing disease is only one that is "diagnosed by a physician within 48 months prior to the effective date of the policy issued by the insurer or its reinstatement" or "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 issued by the insurer or its reinstatement".

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