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Waiting Period In Health Insurance

17 June 2022, 1:03 PM

The specific period of time during which you cannot claim any or some benefits from your insurer. This means that you have to wait for a certain period of time before placing any claim to the insurance company. The terms and conditions and the duration of the waiting period may vary between different companies. During the waiting period, you cannot claim any coverage or benefit from the health insurance company.

Need for Waiting Period in any Health Insurance Policy

There have been several instances where the customers have resorted to unfair means to acquire health insurance policies. Customers have bought a health insurance policy hiding facts, after they have been diagnosed with a specific disease, knowing that the treatment for the same would be expensive. They do this to evade bearing the cost of treatment or surgery as advised by their doctor. The Insurance companies, in order to do away with such dishonest practices, have introduced the clause of the waiting period in their various health insurance policies. Thus, the waiting period in a health insurance policy refers to the time span you have to wait, from the start of your policy, before you can begin to claim any benefits or coverage of the policy.

Different Types of Possible Waiting Periods in Health Insurance Plans in India

Various types of waiting periods are there in different Health Insurance policies. Let us take a look at them and what they imply.

  1. Initial Waiting Period
    The cooling period in health insurance policies or the initial waiting period of a policy refers to the total time you have to wait from the date of issue of the policy, before you are able to gain from its benefits and start using them as and when required by you. Usually, as per industry standards, all health insurance policies have a minimum period of one month as their cooling period or initial waiting period.
    However, the clause of the Initial Waiting period is not applicable to any claims of Health Insurance related to accidental hospitalisation.
  2. Waiting Period for Pre-existing Diseases (PED)
    Insurance Regulatory Development Authority of India (IRDAI) sets the standard that any disease, condition, injury or ailment which has been diagnosed up to 48 months prior to buying the health insurance policy, is considered as a pre-existing disease. Generally, when you buy a health insurance policy, the insurance company will ask you to submit certain specific diagnostic reports that may highlight or confirm the presence of your pre-existing diseases. Some examples of pre-existing diseases are thyroid, hypertension, diabetes, etc. Hence if you have any pre-existing disease, you will have to wait for the cooling period of the policy to be over, for you to claim any benefits or hospitalisation claim related to any of your pre-existing diseases.
    The usual Waiting period for PED or pre-existing diseases is 3 to 4 years depending on your type of health insurance plan and your health insurance policy.
  3. Waiting Period for Specific Diseases
    This implies that you have to wait for the mentioned waiting period in case of any health insurance claim for the treatment and hospitalisation related to a list of specific diseases as prescribed by your Health Insurance company. The waiting period for these specific diseases, on average, is 2 to 4 years.
    The list of specific diseases to which the waiting period is applicable is as follows:
    a. Cataract, Glaucoma of the eye, Retina disorder
    b. Hernia of all sites
    c. Varicose veins 
    d. Gastric and Duodenal Ulcers/Erosions, Pancreatitis, Cirrhosis of Liver, Varices of GI tract, Rectal Prolapse, Calculus disease of the urogenital system, biliary tract and gallbladder
    e. Fissure, Fistula and Pilonidal Sinus, Cyst, Haemorrhoids
    f. Internal Congenital Anomaly
    g. Arthritis, Osteoarthritis and Osteoporosis (if age-related), Systemic Connective Tissue Disorders,  Dorsopathies, Spondylopathies, Arthrosis, Inflammatory Poly arthropathies, Intervertebral Disorders (unless caused by an accident)
    h. Varicocele / Hydrocele, Spermatocele, Hyperplasia of Prostate
    i. Mass or lumps including breast lumps (unless malignant), Cyst, Nodules, Polyp, Sinus, Swelling, all internal and external benign or In Situ Neoplasms/Tumours
    j. Psychiatric disorders or illnesses like Schizophrenia, schizotypal and delusional disorders, Neurotic, stress-related and somatoform disorders, Mood affective disorders
    k. Neurodegenerative disorders include but are not limited to Alzheimer’s disease and Parkinson’s disease
    l. The disease of the mastoid and middle ear includes otitis Media, Perforation of the Tympanic membrane, Cholesteatoma, Tonsillitis, Sinusitis, Nasal Septum Deviation, Nasal Polyp, Mastoiditis, Nasal Concha Bullosa, Turbinate Hypertrophy
  4. Waiting Period for Maternity Benefit and New Born Baby Cover
    For those who are planning to go the family way soon, there is an option of adding Maternity benefits and including an add-on for a newborn baby as a part of almost all health insurance policies that cover maternity benefits. It is a prudent decision to plan ahead for the inevitable expenses to be incurred during and post-pregnancy.
    As per the industry standards, on average, the waiting period for maternity benefits and newborn baby coverage add-on ranges from one year to four years, depending on your choice of plan. This means that ideally, you can claim the expenses of maternity and for the newborn child only after the waiting period as mentioned in your policy, for this clause, is over. 
    The maternity benefit add-on covers the expenses related to the delivery of the child and the expenses required for the care of the newborn, including the necessary vaccinations and other medical care, for the first 90 days from the date of delivery.
  5. Waiting Period for Bariatric Surgery
    In today’s times, some Health Insurance Policies include Bariatric Surgery. Bariatric surgery refers to the surgery of the stomach and/ or intestines to control extreme obesity issues in some people. People with a BMI above 40 and having health issues related to the same are advised to go for surgeries by their medical practitioners. Some plans cover this surgery without any additional cost or premium. For the plans which cover Bariatric surgeries, generally have a waiting period of 2 years.
  6. Waiting Period for Accidental Hospitalisation
    Given the unpredictable and unexpected nature of accidents, no waiting period is accounted for, in case of accidental hospitalisation claims, by any Health Insurance Companies. The initial cooling period/waiting period of the policy/plan does not apply in case of accidental hospitalisation claims, either. 
    This means that you are covered for any accidental hospitalisation claim even if you have taken the policy just a few days back.
  7. Waiting Period for Complimentary Annual Health Check-up
    The expenses of Complimentary Annual Health Check-up benefit is covered by some Health Insurance Policies. However, there might be a small waiting period, for this benefit which may differ across different plans taken from different insurance providers. This means that the cost of your complimentary health check-up can be claimed from your insurer after the waiting period for the same is over.
  8. Waiting Period of Coronavirus
    It has now almost become mandatory to get yourself covered for this deadly virus, as the number of cases of Coronavirus is still increasing in India. People have got into a frenzy of buying online policies covering themselves and their family members for the treatment and hospitalisation related to this disease. 
    As an industry standard, the waiting period is up to 30 days, for coronavirus related treatment and hospitalisation.

Can Waiting Period Be Reduced?

Waiting Period, in some Health Insurance Policies, can be reduced by paying a higher premium. 

  • In Group health policies, that is, insurance policies provided by the employer to its employees, their waiting periods are not insisted upon by the health insurance companies, in most cases.
  • IRDA provides the facility to an individual to convert his/her group plan policy into an individual cover plan at the time of leaving/switching their employment. In such cases, the plan gets converted without any waiting period as the employee had already served the waiting period while he was a part of the group plan.

Other Important Things To Remember in Regards to Waiting period 

If the insured person has been diagnosed with any disease for the first time, during the period of waiting, then it will not be considered as a PED or pre-existing ailment as the same did not exist or was not diagnosed at the time of filling up the form or policy inception. Only if the ailment had already been diagnosed or is being treated, is considered as a pre-existing ailment.

Insurance companies have now started to do away with the waiting period for senior citizens by including a co-pay clause in such plans. A certain percentage of claim amounts will have to be borne by the policyholder as implied by the co-pay clause of the specific policy.

Now that you are updated on all important details of the waiting period, do check out for the shortest waiting period when you invest in a new health insurance plan!

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