It’s vital to know the details of the waiting period clause in your health insurance
Insurance regulator IRDAI has mandated that the waiting period for pre-existing diseases should not go beyond four years (48 months) in any health policy, effective October 1. But this is not the only waiting period component in a health policy.
For instance, if you sign up for a new health policy, you will have to wait for a minimum period before your health cover starts.
Maternity covers and some other specified diseases also have a waiting period before claims can be entertained.
Waiting period ensures that insurers do not cover for claims that are certain and predictable. The clause helps prevent their losses. Waiting period is an important clause and every policyholder should be aware of its nuances to avoid unnecessary hassles at the time of claim.
Waiting period, which is applied from the date of policy commencement, varies depending on the ailments, and differs from one insurer to another.
If you buy a health plan, you have to mandatorily wait for a period of 30 days, known as initial waiting period, from the date of commencement of the policy. During this period, the insurance company will not admit claim for diseases or hospitalisation except for accidental injuries, provided the policy covers such accidental injuries.
Now, if an individual has an existing medical condition (known as pre-existing medical condition) before the commencement of health policy, he/she has to wait for a few years before the cover begins. However, excluding that particular medical condition, the policyholder will be covered for other illnesses/accidents, post initial waiting period.
The ‘pre-existing waiting period’ is usually 48 months among most insures but some insurers have only 24-36 months as pre-existing waiting period.
For instance, for Optima Restore policy from HDFC Ergo Health, the pre-existing waiting period is 36 months.
There is another type of waiting period for specific diseases or specified procedure and this, too, varies from one insurer to another. Insurers usually have a common list of specific diseases or a list of medical treatments for which this waiting period will apply.
For instance, ManipalCigna’s ProHealth policy has a disease/procedure-specific waiting period of 24 months (two years), after which the expenses for the same will be covered. The list of specific diseases/procedures includes cataract, knee replacement surgery (other than caused by accident), and varicose veins or ulcers.
But keep in mind that if these diseases exist at the time of taking the policy or it is subsequently found that they are pre-existing, the pre-existing diseases waiting period will apply.
Insurers usually have a waiting period of 90 days (from the date of commencement of policy) in case of critical illness or lifestyle-related diseases, including cancer, hypertension and cardiac conditions.
Health policies that offer maternity covers also have waiting period (for mothers and new-borns). Any treatment arising from pregnancy to childbirth including Caesarean sections will be covered under a policy only after the expiry of the waiting period. For instance, ProHealth policy from ManipalCigna covers maternity expenses only after expiry of 48 months. Similarly, Digit Insurance’s health policy, too, has a two-year waiting period for maternity cover.
Lastly, most insurers have personal waiting period which may be applied (from the date of policy commencement) to individuals depending on the declarations made by him/her at the time of taking the policy and the existing medical conditions. Factors including medical history, pre-existing medical conditions, medical test results and current health status will be taken into account by the insurer for applying this waiting period.
In Max Bupa’s ReAssure policy, for instance, personal waiting period is applicable for a maximum of 24 months, while in ProHealth policy (ManipalCigna), it is applicable for a period of 48 months. Personal waiting period will be specified in your policy document and will be applied only after you give your consent. If you decline, your application will be cancelled and premium, if any paid, will be refunded.
But most of the time, personal waiting periods are not applied by the insurers.
Points to note
There are a few points to keep in mind about the waiting period clause in health insurance.
One, you can reduce your waiting period. If you feel the pre-existing or disease-specific waiting period is too long, some insurers let you reduce the same.
But you might have to cough up additional premium.
For instance, in the case of ICICI Lombard’s Complete Health insurance policy, you can reduce the pre-existing waiting period if you opt for sum insured (SI) over ₹2 lakh.
The waiting period comes down to 24 months from 48 months. Similarly, in ProHealth policy (ManipalCigna), you can reduce your waiting period if you opt for a higher variant of the policy.
The pre-existing waiting period is reduced to 24 months in ‘Plus’ and ‘Accumulate’ variant while it is 36 months for the ‘Protect’ variant and 48 months in other variants.
Two, if you renew your health policy without any break in premium payment, the policy continues to cover you.
But if you renew your policy after a break, you may have to undergo another waiting period similar to what a new policy entails.
At the time of porting, too, if you continue the policy without any break, your waiting period will be as per the new policy or as per your health status at the time of porting.
However, if you enhance your SI (at the time of porting as well as in an existing policy), the waiting period shall apply afresh to the extent of increased SI.