Why disclosing pre-existing diseases is key when buying health insurance

So, what counts as a pre-existing condition, how far back must you go in your medical history, and are there any exceptions? Here’s a detailed look.

What counts as a pre-existing disease

The term ‘pre-existing disease’ typically refers to any condition, illness, or injury that an individual has been diagnosed with or treated for before purchasing the health insurance policy.

This includes chronic ailments like diabetes, high blood pressure, asthma, chronic kidney disease, heart-related issues, epilepsy, and others that require ongoing treatment or have long-term effects on health. Serious health episodes requiring hospitalization—like surgeries, strokes, or cancer—also fall into this category.

If the applicant misses disclosing issues like a viral fever or an old injury that was treated and cured, it will generally not be an issue.

How far back do you need to go

There is often confusion around how many years of medical history need to be disclosed. There is no official limit or exhaustive list that prescribes a specific time frame.

Instead, what matters is whether the condition is material to the insurer’s underwriting decision. “The insurer should not have any grounds to suspect that there was a wilful attempt to hide certain information to mislead the insurer, as that could become legitimate grounds for claim rejection,” explained Shilpa Arora, co-founder and chief operating officer at Insurance Samadhan.

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This means that even if a condition was diagnosed long back, it may be material to the insurer’s underwriting decision and thus it’s advisable to disclose it.

Principle of utmost good faith

Health insurance contracts, like all insurance products, are built on the principle of “utmost good faith”. This means both the insurer and the insured are obligated to be completely transparent.

For policyholders, this means disclosing relevant facts that could affect the insurer’s decision to issue the policy or determine the premium. For the insurer, it means clearly stating all terms, conditions, limitations, and exclusions in the policy.

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“It is advisable to make all disclosures, especially all the critical incidents. Instead of deciding what is critical and what is not, customers should let the medical underwriting team of insurers take the call on disclosures. Of course, forgetting small incidents like cough, cold, and fever, is fine,” said Parthanil Ghosh, executive director of HDFC Ergo General Insurance Company.

Moratorium period

Insurance Regulatory and Development Authority of India (Irdai) regulations offer protection to policyholders in the form of a moratorium period. If a health insurance policy has been continuously active for five consecutive years, the insurer cannot reject any claim on the grounds of non-disclosure or misrepresentation, except in cases where fraud is established.

So, even if an unintentional error of omission was made in the initial proposal, the claim rights will be protected after the moratorium period.

Waiting period

As per regulations by the Irdai, any illness that is diagnosed or for which medical advice or treatment was received within 36 months from the effective date of the health insurance policy is classified as a pre-existing disease, for the purpose of waiting period.

Such diseases will only be covered after a certain waiting period by the insurer.

“These diseases will only be covered after a certain waiting period. The regulations stipulate that such diseases can be covered after a maximum waiting period of three years. This would also include diseases that have been treated and cured within this period,” said Abhishek Bondia, principal officer and managing director at SecureNow Insurance Broker.

Some insurers may reduce the waiting period to two years with certain riders. “Applicants can use riders to even reduce the waiting period to one month for chronic illnesses, for 18-20% higher premium,” said Siddharth Singhal, head of health insurance business, Policybazaar.

After receiving all the material medical disclosures from the customer, the insurer may decide to exclude certain diseases from the policy’s coverage altogether. 

It depends on the final terms and conditions the insurer decides after considering all the relevant information of the insured.

Common misconceptions

A common misconception is that disclosing a pre-existing condition will automatically lead to a policy rejection or steep premiums.

“In reality, most insurers expect some medical history and have mechanisms to manage such risks. These include waiting periods for PEDs, premium loading, or exclusions for certain high-risk conditions,” said Nisha Sanghavi, director, Promore Fintech, and certified financial planner.