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All About Pre Policy Medical Check Up in Health Insurance

28 June 2022, 2:42 PM

Pre-policy medical check-ups can be referred to as the medical check-up or examinations which are requested by the health insurance providers before coverage is being provided. Those applicants who are over a particular age group are required to go for the pre-policy medical check-ups. So, if you are buying a health insurance plan for your family, depending on the age group, certain family members may require a medical checkup.

Importance of Pre-policy Medical Check-up For Insurance Providers

Pre-policy medical check-ups are a group of medical tests or procedures which a policyholder would have to undergo if he/she is above the age group of 40-45 years. By this, the insurance provider would be aware of the applicant's medical conditions and also know if there are any pre-existing medical conditions. 

Moreover, if the policyholder is opting for a sum insured that is above the average amount then it can cause an increase in the risk of the insurance provider. So, basically, each and every insurance company would have a grid for pre-policy medical checks. For example, if the non-medical limit is INR 10 lakhs and 45 years, then any applicant less than 45 years of age, opting for a health insurance plan up to INR 10 lakhs would not have to undergo a series of medical tests before the policy is granted to him.

What is a Pre-policy Medical Check-up Grid?

For example, the medical grid of Care Policy is listed below:

Age/Sum Insured including deductibleUp to INR 5 LakhsINR 5 lakhs to INR 15 lakhsINR 15 lakhs to INR 30 lakhsINR 30 lakhs to INR 1crore>INR 1 crore
Up to 17 yearsNo medical tests neededMERMER

For Floater Policy –MER

For Individual – Set 2

18 to 24 yearsSet 1Set 2Set 6
25 to 45 yearsSet 5Set 7Set 9
46 years and aboveSet 3Set 4Set 5Set 8Set 10

The list of medical tests are:

CategoryMedical Tests
Set 1MER, CBC, FBS, RUA, SGPT, S. Creatinine
Set 2MER, CBC, FBS, RUA, ECG, USG, S. Creatinine
Set 3MER, CBC &ESR, FBS / HbA1c, T.Cholesterol, ECG, SGPT, S. Creatinine
Set 4MER, CBC &ESR, FBS / HbA1c, T.Cholesterol, TMT, SGPT, S. Creatinine
Set 5MER, CBC, HbA1c, Lipids, LFT with GGT, RUA, TMT, HBsAg, S. Creatinine
Set 6MER, CBC, FBS, RUA, 2DEcho, USG, S. Creatinine
Set 7MER, CBC, HbA1c, Lipids, LFT with GGT, RUA, TMT, HBsAg, S. Creatinine, USG abd/pelvis (M&F)
Set 8MER, CBC, HbA1c, Lipids, LFT with GGT, RUA, Stress Echo, HBsAg, RFT, USG abd/pelvis (M&F), PSA (M)
Set 9MER, CBC, HbA1c, Lipids, LFT with GGT, RUA, Stress Echo, HBsAg, RFT, USG abd/pelvis (M&F), CEA, PSA (M), PAP(F)
Set 10MER, CBC, HbA1c, Lipids, LFT with GGT, RUA, Stress Echo, HBsAg, RFT, USG (M&F), CEA, PSA (M), PAP (F), Chest - X-Ray, PFT, TSH

The name of medical tests are:

MER Medical Examination Report
CBC with ESR Complete Blood Count with Erythrocyte Sedimentation Rate
RUA Routine and Microscopic Urine Analysis
HbA1C Glycosylated Haemoglobin
S. Cholesterol Serum Cholesterol
Lipids Fasting Lipid Profile
ECG Electrocardiogram
SGPT Serum Glutamic Pyruvic Transaminase
S. Creatinine Serum Creatinine
TMT Treadmill Test
2 D Echo 2D Echocardiography
LFT Liver Function Test
PSA Prostate Specific Antigen
HBsAg Hepatitis B Surface Antigen/Australian Antigen
PAP Papanicolaou Test
USG abd / Pelvis Ultrasonography abdomen and Pelvis
TSH Thyroid Stimulating Hormone
PFT Pulmonary Function Test
CEA Carcino Embryonic Antigen
RFT Renal Function Test
T.Cholesterol Total Cholesterol

So, if a 42-year-old person opting for INR 50 lakhs of coverage would have to undergo pe-policy medical check-ups of Set 7, as per the grid. The Set 7 list of medical tests is MER, CBC, HbA1c, Lipids, LFT with GGT, RUA, TMT, HBsAg, S. Creatinine, USG abd/pelvis (M&F), i.e. Medical Examination Report, Complete Blood Count, Glycosylated Haemoglobin, Fasting Lipid Profile  Test, Liver Function Test with Gamma-glutamyl Transferase test, Routine and Microscopic Urine Analysis, Treadmill Test, Hepatitis B Surface Antigen/Australian Antigen, Serum Creatinine, Ultrasonography abdomen and Pelvis.

Importance of Pre-policy Medical Check-up for Policyholders

A pre-policy medical check-up is also important for the policyholders. The major reason for this would be to have awareness about their health condition. The applicant might be suffering from some illness and would be completely unaware of it. If he undergoes a pre-policy medical test then he would become clear about his current health conditions.

The pre-policy medical tests would also be important when a policyholder files insurance claims. If a health insurance claim is made by a policyholder but the insurance company would reject the claim stating a reason for   a pre-existing condition that was deliberately hidden from the insurance provider. But, if there is a pre-policy medical check-up, the health condition of the applicant would be on the medical file thus, making it easier for investigation at the time of insurance claim.

What are the Tests Included in the Pre-policy Medical Check-up?

Different health insurance companies have different parameters for the assessment of risk. The most common tests which are a part of the pre-policy medical check-up are the Electrocardiogram (ECG), Complete Blood Count (CBC), High blood pressure screening, lipid profile which would include the test for certain abnormalities in the cholesterol and other lipids, blood sugar screening, serum test which includes the test for albumin in the blood, etc. 

Based on the results of these pre-policy medical check-ups, your health insurance providers would determine the sum insured and the premium of your health insurance plan. 

Payment for the Pre-policy Medical Check-up

  1. As per the regulations of the IRDAI, half of the costs of the pre-policy medical check-ups would be paid by the insurance provider and half of the balance would be paid by the policyholder.
  2. However, some health insurance companies would pay off the entire cost of the pre-policy medical tests to reduce the liabilities on the policyholders.
  3. Moreover, some health insurance companies would also instruct the policyholders to pay for the pre-policy medical check-ups themselves which would be further reimbursed by the insurance company after the policy has been purchased.

Pre-policy Medical Check-up Procedure

The steps involved in the pre-policy medical check-up are as follows:-

  1. The applicant would have to fill up the insurance application form and submit it to the Health Insurance Company.
  2. If the applicant is found applicable for the pre-policy check-up then he would receive a call for scheduling the pre-policy health check-ups.
  3. There would be a list of health or medical centres designated by the health insurance provider and the applicant would have to select a medical centre amongst those on the list.
  4. The applicant would be informed about any specific measures which must be taken by the applicant such as fasting before the test or any other specific measures.
  5. The date, time, and location for the medical test would be informed to the applicant by the health insurance company.
  6. An authorisation letter would be provided to the applicant by the insurance provider to carry it for the test.
  7. The payment for the medical check-ups would be done by the applicant or not would be based on the rules of the company.

After the Pre-policy Medical Check-up 

Once the procedure for the pre-policy medical check-up is over, the following scenarios can be expected.

  1. If there are no signs of illness in the medical test reports; the health insurance company would accept the application and inform the applicant about it.
  2. If there has been the detection of any prolonged or deadly illness in your pre-policy medical check-up reports then the following scenarios can happen.
  • Premium Increase & Waiting Period – The health insurance company would issue the health insurance policy to the individual but at an increased premium. Also, there might be a waiting period of 2 or 4 years, which means your illness will be covered after this period.This rise in the premium would help in providing coverage for the illness or the health conditions that have been detected.
  • Exclusions – The health insurance company would issue the insurance plan but would exclude the detected illness from the cover which is being provided to the applicant. So, the applicant would not be able to make any claim in case of hospitalisation received for the illness/health condition detected.
  • Rejection – If the health condition or illness detected is of a very high risk then the application for the insurance policy would be rejected by the health insurance company.

Conclusion

However, there are a large number of health insurance plans which would not make pre-medical check-up mandatory. But, if a pre-medical check-up is done then it would be quite beneficial in the long run. It would help in also reducing the possibilities of health insurance claim rejection in the future. So, you should not be worried about the costs of the pre-medical check-ups and avail of comprehensive health insurance to ensure financial stability during adverse times.

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