Pre-existing disease

What is a pre-existing disease?

A pre-existing disease, or PED, is a health condition the insured person already had when the policy began. Since 1 April 2024, IRDAI defines it in Schedule III of the IRDAI (Insurance Products) Regulations, 2024 as any condition, ailment, injury or disease that was diagnosed by a physician, or for which medical advice or treatment was recommended by or received from a physician, not more than 36 months before the policy started.

Conditions that fall within this definition must be disclosed in the proposal form. Once disclosed and accepted, they are covered after the PED waiting period, which can be at most 36 months of continuous cover.

How pre-existing diseases are treated in India

The 2024 regulations changed both the look-back period and the waiting period:

Practical effects of the definition:

• The test is diagnosis, advice or treatment by a physician. A condition first diagnosed or treated more than 36 months before the policy began falls outside the definition. A condition within that window must be declared even if the person feels well.
• Disclosure decides coverage. The insurer can accept the condition with the standard waiting period, add a loading, apply a shorter or longer wait within the regulatory limit, or in some cases decline, according to its board-approved underwriting policy. IRDAI requires insurers to offer products for people with all kinds of existing conditions, though not every product has to cover every condition.
• Travel policies are different. The PED definition and the 36-month waiting cap do not apply to overseas travel policies.
• Moratorium closes the door on old disputes. After 60 months of continuous cover, including time under ported or migrated policies, no claim or policy can be contested for non-disclosure or misrepresentation except on grounds of established fraud. See moratorium period.

If a condition is not disclosed and the insurer finds out within the first 60 months, it may reject a related claim or act against the policy under its terms. Health insurance is a contract of utmost good faith, and IRDAI's Customer Information Sheet asks the policyholder to disclose all pre-existing conditions, warning that non-disclosure may affect claim settlement.

What pre-existing disease means for distribution

PED is where health insurance sales and claims most often collide. Rejections for non-disclosure damage trust in the insurer, the distributor and the product category.

What a good adviser and a well-run sales team do:

• Ask the questions properly. Read the medical questions to the customer, or make sure they read them, rather than ticking "no" on their behalf. Filling the form for the customer is a common route to a disputed claim and a mis-selling complaint.
• Explain the 36-month window in plain words. "Anything a doctor diagnosed, advised or treated in the last three years" is easier to understand than the regulatory wording.
• Treat common conditions as normal. Diabetes, high blood pressure and thyroid disorders are common. Customers often fear that disclosure means rejection. Explain that disclosure usually means a waiting period or a loading, and that non-disclosure is the bigger risk.
• Offer products built for conditions. Many insurers sell products with shorter PED waiting periods, or covers designed for people with diabetes or heart conditions, sometimes with a co-payment. Match the product to the customer rather than pushing a standard plan.
• Protect continuity. A customer who has served part of the PED wait should port or migrate, not start a fresh policy, so the credit carries over.
• Senior citizens. Older customers almost always have some PED. Plans with clear PED terms, and premium protections such as IRDAI's 10% annual increase limit for senior citizen individual indemnity products from January 2025, should be explained together.