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Are Congenital Diseases Covered by Indian Health Insurance?

By Juhi Walia
26 August 2022, 12:59 PM

Usually, a nutritious diet, enough sleep, and regular exercise help prevent sickness and physical weakness. Individuals born with congenital diseases, on the other hand, appear to develop these ailments despite following healthy habits. Treatment costs for congenital diseases could be too expensive and out of reach for many. Some of us may even have to sell our precious items and exhaust our savings earned over the years to arrange the sum for treatment. It can help you recover but impair you financially. On the other side, you must know whether health insurance covers congenital diseases and keeps your savings intact for other useful means. Here we will understand the basics of congenital diseases and whether they are covered by health insurance policies in India

What is Meant by Congenital Diseases?

Congenital diseases are illnesses present in individuals from birth. These are functional or structural deformities that occur during a baby's intrauterine life. They are also known as congenital malformations or genetic disorders and can be identified before, during, or after delivery.

Some of the most prevalent causes of congenital malformations in infants are genetic mutations, environmental variables, maternal age, maternal nutritional condition, infections, and socioeconomic factors.

According to a study by WHO in 2016, approximately 1.7 million persons in India suffer from congenital illnesses, accounting for 6-7% of the entire population. While internal congenital disorders are not always obvious, external congenital malformations are. Nonetheless, a newborn born with a congenital disease may have health issues or be disabled for the rest of his or her life.

Common Congenital Diseases

The following are some most prevalent congenital diseases:

  • Down syndrome
  • Cystic fibrosis
  • Cerebral palsy
  • Edward’s syndrome
  • Cleft lip and cleft palate
  • Club foot
  • Phenylketonuria
  • Congenital hypothyroidism
  • Fragile X syndrome
  • Spina bifida
  • Sickle cell disorder
  • Congenital heart disease
  • Thalassaemia

Congenital Disease Treatment

A congenital disease's therapy is determined by its diagnosis and type. Most functional congenital illnesses in kids can be treated with medicine in the early stages to treat symptoms and prevent consequences.

Children with structural congenital anomalies, on the other hand, may require paediatric surgery to repair the problem. It goes without saying that both long-term medicine and pediatric surgery will be costly.

Furthermore, doctors may ask a pregnant woman to undergo a battery of tests to diagnose a possible congenital condition.

Although some congenital disorders, such as Down syndrome, can be diagnosed prenatally with a blood test, others may necessitate chorionic villus sampling (CVS), ultrasound scans, amniocentesis, and other procedures to diagnose the ailment. These examinations can eat into your savings too.

While some congenital illnesses, like down syndrome, can be identified with a blood test during pregnancy, others may need further testing to be spotted, such as CVS, ultrasounds, amniocentesis, etc. These exams can drain your bank account due to their high cost.

Do Indian Health Insurance Plans Cover Congenital Diseases?

Yes. According to IRDAI's 2019 guidelines, all normal health insurance policies in India cover congenital disorders. 

These policies pay for the costs of in-patient hospitalisation, day care procedures, surgeries, pre-hospitalization, post-hospitalization, and other medical expenses related to the diagnosis and treatment of congenital illnesses. The coverage amount might be anywhere between INR 50,000 and Rs. 6 crores. However, the extent of coverage and the covered amount depends on your chosen health insurance policy.

In India, however, health insurance does not necessarily cover all congenital illnesses. Only internal congenital illnesses are covered by standard health insurance plans according to IRDAI guidelines. The health insurance provider is not required to cover the cost of therapy if a person has an external congenital condition.

The Congenital Disease Waiting Period For Health Insurance Plans

Although internal congenital illnesses are covered by health insurance policies in India, you cannot access coverage until the waiting period has passed. After a 2-year waiting period, congenital disorders are typically covered by health insurance policies.

This means that it will need two renewals in a row before you may submit a claim for congenital disorders under your health insurance. You may easily persuade your insurance company to cover the cost of treating internal congenital illnesses once the waiting period is completed.

Congenital malformations, however, have a 2-year waiting period that only applies if your child is identified with the condition after you've purchased health insurance. It will be regarded as a pre-existing condition if your child was identified as having an internal congenital ailment before purchasing the plan.

In that situation, you would have to wait up to four years before submitting a health insurance claim under your coverage for congenital disorders. This is due to a 2-4 year waiting time before all pre-existing conditions are covered by health insurance companies.

As a result, carefully read your policy documents to determine the precise waiting period for pre-existing conditions and congenital diseases.


Congenital illnesses have long-term effects. Your child won't just have to deal with various health issues throughout his or her life; the cost of therapy will quickly deplete your funds as well. The good news is that internal congenital illnesses are covered by health insurance policies in India. However, it is preferable to adhere to the preceding advice and make every effort to keep your child from getting a congenital illness.

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1. Does health cover all congenital conditions?

Not all congenital illnesses are covered under health insurance. According to IRDAI regulations, internal congenital conditions may be covered by health insurance. External circumstances, however, might not be covered. These external problems can include lumbar spina bifida, clubfoot, cleft lip and palate, and others.

2. What factors can result in congenital diseases?

  • The function of one or more genes may be compromised by a change or mutation.
  • Chromosome abnormalities
  • Exposures to drugs, chemicals, or other harmful materials
  • Pregnancy-related infections.
  • A deficiency in some nutrients.

3. Is congenital a synonym for genetic?

Congenital illnesses are those present at birth or in the first few years of life. In general, many genetic illnesses do occur at birth and are categorised as congenital. On the other hand, many congenital illnesses are inherited or have a large genetic component.

4. How are congenital disorders passed down?

It is possible to link inherited genes or mutations to genetic causes. When parents are congenitally linked, the likelihood of congenital abnormalities rises and the chance of neonatal and early childhood mortality, intellectual disability, and other health issues virtually doubles.

5. How soon after conception may birth abnormalities be found?

Combining several tests, first trimester screening is carried out between weeks 11 and 13 of pregnancy. It is used to check for chromosomal diseases, including Down syndrome, or birth problems connected to the baby's heart. An ultrasound and a maternal blood test are part of this screening.

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