Does Group Insurance Cover Pre-Existing Conditions?

Group health insurance is a type of health insurance policy that covers the hospitalization expenses of a group of members under a single master policy in return for a nominal amount known as Premium. The group health insurance policy is usually taken by an employer for their employees and the premium is paid by the employer in most cases.

There might be premium sharing arrangements in group health insurance policies in which the employees pay a certain percentage of the premium whereas the employer pays a certain percentage of the premium. There are group health insurance policies in which the premium for extra sum insured or Premium for parents has to be borne by the employees.

Group insurance is a customized health insurance policy where the customer has the option to avail of the coverage as required without the need to opt only standardized health insurance policy. Group insurance products are designed in such a way that it suits the requirements of all, unlike traditional health Insurance which doesn’t suit everyone’s needs.3

• Pre-existing conditions: Group health insurance policy has a condition known as pre-existing disease waiting period. Pre-existing disease waiting period is the condition under which the insured customer has to wait for a certain period of time before making a claim under the policy. The pre-existing waiting period under the group health insurance ranges from 1 year to 4 years depending on the insurance company.

The pre-existing diseases or illnesses are those which are present before the inception of the policy. As per the definition of IRDA pre-existing condition is defined as any condition, ailment or injury, or related condition(s) for which there were signs or symptoms, and/or were diagnosed, and/or for which medical advice/treatment was received within 48 months prior to the first policy issued by the insurer and renewed continuously thereafter.

In simple terms any condition or illness or disease which exists prior to the inception of the group health insurance policy. Any claim arising out of or related to pre-existing conditions would have a waiting period of 1 year to 4 years during which the claim would not be paid.

A group health insurance policy as discussed above is a customized health insurance policy in which the pre-existing condition would be covered if the option is exercised by the insured at the time of taking the policy.

Pre-existing disease waiting periods can be waived off under the group health insurance policy on payment of an additional premium. In addition to the pre-existing disease waiting period, the initial waiting period and specific disease waiting period can also be waived off under the group health insurance policy.

• Waiting period for PED: Group health insurance policies are designed in such a way to provide a waiver of pre-existing conditions waiting period. For example, an organization can take the group health insurance policy with a pre-existing period waived off completely and the coverage available from day one.

Unlike the retail health insurance policies which insist on the declaration of pre-existing diseases, the group health insurance policies do not have any condition to declare the pre-existing diseases as they can be waived off and coverage can be availed from day 1.

A condition would be considered as pre-existing only if the insured customer is aware of the condition and has undergone any kind of treatment for the same. If the customer is not aware of the illness or disease at the time of taking the policy then the illness cannot be termed as pre-existing illness.

Only conditions which are existing prior to the inception of the policy would be considered pre-existing conditions and the waiting period would be applicable accordingly.

Failure to notify the insurance company regarding the pre-existing diseases can result in a repudiation of claims in retail health insurance policies. In group health insurance policies the pre-existing disease waiting period can be waived off, thereby providing the members of the group health insurance policy with day 1 coverage.

The major advantage of a group health insurance policy is that pre-existing diseases can be covered from day 1.

Senior citizens and parents of employees in a group health insurance policy can avail of this advantage as it would be very difficult for aged people with pre-existing conditions to get a retail health insurance policy as most insurance companies reject the proposals.

• Health insurance with PED cover: It is possible to avail of a health insurance policy with a pre-existing disease cover where the pre-existing diseases are covered by the insurance company. For example, Mr. Rahul aged 40 years has a diabetic condition that was detected 4 years ago and he has to take medication to keep the disease in control.He has approached an insurance company to take a retail health insurance plan for himself and his family. While filling out the proposal form there was a section about pre-existing diseases which mentioned that all the pre-existing diseases which exist prior to the inception of the policy would be covered only after a waiting period of 3 years whereas few other pre-existing diseases such as congenital diseases are not covered even after a certain waiting period.Rahul works in an MNC which offers him group health insurance coverage for ₹5 lakhs and the terms and conditions of the policy mention that the employees can include their spouse, children, and parents in the policy on payment of additional premium.The group health insurance policy doesn’t have a pre-existing waiting period under which the members of the policy need to wait for a certain period before making the claim. The members of the group health insurance policy can avail health insurance coverage from day 1 even for pre-existing illnesses.

In this way, Rahul can avail of the pre-existing condition waiver with the group health insurance policy and get additional cover with the retail health insurance policy but with the condition of the waiting period.

Parents of Rahul can enjoy the health insurance cover from day 1 without the need to wait for a certain period to claim the pre-existing diseases under the group health insurance policy, whereas they need to wait for a certain period of 1 year to 4 years under the retail health insurance policy.

All the other waiting periods, such as the initial waiting period or 30-day waiting period, and specific disease waiting periods can be waived off under the group health insurance policy.

For more information on the coverage under the group health insurance policy, please book a call with Ethika insurance to get assistance from health insurance experts.

• Pre-Existing Conditions Covered in Group Health Insurance: The group health insurance policy covers all pre-existing diseases if the option is exercised by the insured at the time of taking the policy. Under the group health insurance policy the pre-existing conditions are covered from day 1 without the need to wait for a certain period.

There are many pre-existing diseases that are covered under the group health insurance policy such as:-

•  Asthma
• Diabetes
• Hypertension
• Blood pressure
• Thyroid
• Cancer
• Depression and other mental conditions also come under pre-existing illnesses.