My health insurance policy started on 29 June 2022. I went through a treatment for a disease in October 2016. The period between the last medication or treatment and the policy start date is over 56 months. Per regulations, pre-existing conditions are defined as those diagnosed within 36 months of the policy purchase date. I underwent a surgery on 29 August 2024. Will my claim for the latest surgery get reimbursed?
-Name withheld on request
In this situation, the claim for the surgery cannot be reimbursed due to the 36-month waiting period for pre-existing diseases (PEDs). As per standard insurance guidelines, a PED is defined as any illness or condition that was diagnosed or treated within a certain period before the policy was taken. In this case, the policy started on 29 June 2022, and the surgery took place on 29 August 2024, meaning that the policy has not yet completed the 36-month waiting period for PEDs.
One key aspect to understand is that the waiting period for PEDs begins from the date the policy starts, not from the date when the illness or condition was first diagnosed or treated. This means that even if the condition or illness occurred well before the policy inception date, such as in this case, where the last treatment was in October 2016, the waiting period still applies, starting from the policy inception date.
Moreover, it’s important to note that the benefit of the waiting period for PEDs is available only for conditions disclosed when purchasing the policy. This means that any PED must be declared and acknowledged by both the policyholder and the insurance company when the policy is taken out. Even if the condition is disclosed properly, the 36-month waiting period still needs to be completed before any claims related to the PED can be considered eligible for reimbursement.
To further clarify, the waiting period is designed to protect insurance companies from immediately paying claims related to pre-existing conditions, ensuring that policyholders maintain coverage for a sufficient period before becoming eligible to make such claims. For example, if the policy had been active for more than 36 months, then a claim for a PED could be reimbursed, assuming all other terms and conditions of the policy are met.
It’s also worth emphasizing that the timing of the surgery—whether it occurs before or after the 36-month waiting period—plays a critical role in whether a claim will be honoured. In your situation, since the policy had been active for only around 26 months by the time of surgery, the waiting period was not fulfilled.
In conclusion, based on the information provided, the claim for your recent surgery cannot be paid because the policy has not yet completed the mandatory 36-month waiting period for PEDs. Additionally, even if you properly disclose the PED, the waiting period still applies, and the claim is not payable.
Shilpa Arora is co-founder and chief operating officer at Insurance Samadhan.