Waiting Periods in Health Insurance Plans

The waiting period in health insurance, as the name suggests, is the period when you need to wait after purchasing your health insurance plan. You cannot avail the benefits of the health insurance policy during this period. The waiting period starts from the date of the commencement of the policy, and the duration may vary for different insurers. It is always advised to check the waiting period of a health insurance plan before you purchase it.

Important Update (Dated May 30, 2024) – Good news for Health Insurance policyholders! According to the Master Circular on Health Insurance Business 29052024 rolled out on May 29, 2024 by IRDAI, insurers are to decide on the request for cashless claims within 1 hour of receiving the request. Also, the final claim is to be granted within 3 hours after the policyholder’s discharge from the hospital. Insurers have been directed by IRDAI to establish necessary systems and procedures for this process by July 31, 2024.

 

The Master Circular on Health Insurance Business 29052024 circular is available here - https://irdai.gov.in/document-detail?documentId=4942918

Waiting periods in health insurance plans help curb any possible unethical practices by the policyholder and lower the risk for the insurer. Without a waiting period, it would become easy for people to purchase policies when anticipating an upcoming medical expense and exploit their full coverage benefits.

 

For instance, you are diagnosed with a critical illness but don’t have an insurance cover in place. Meeting the costs of surgeries or treatment associated with the ailment on your regular income might not be feasible. Thus, you decide to buy a health insurance policy to avail of insurance coverage for the same.

 

However, you fail to report the condition to the insurer before purchasing the policy. This would be treated as malpractice as the insurer is unaware of the condition. Waiting periods in health insurance plans help bypass such unethical practices.

 

Here are the major types of waiting periods in health insurance policies that you must be mindful of:

1. Initial Waiting Period

The initial waiting period in a health insurance policy is the time that must pass before you can start using the benefits of the policy. Also referred to as the cooling period of the policy, the initial health insurance waiting period usually lasts up to 30 days. However, the exact initial waiting period shall vary depending on the health insurance provider you select.

2. Waiting Period for Pre-Existing Diseases (PED)

A pre-existing ailment is any disease with which you have been diagnosed within the last 48 months of purchasing a health insurance plan. At the time of policy purchase, you are required to disclose any pre-existing diseases you may suffer from to your health insurer.

If you end up requiring any medical treatment or hospitalisation due to the pre-existing illness, then you cannot claim insurance coverage for it immediately. You will have to complete the minimum PED waiting period in order to claim coverage for your pre-existing diseases.

3. Waiting Period for Specific Diseases

Health insurance policies also have a waiting period applicable for the treatment pertaining to a specific disease or ailment. Usually, the waiting periods for different diseases are specifically mentioned in your health insurance policy document. Therefore, you must read the fine print and understand the terms and conditions applicable for specific illnesses.

4. Waiting Period for Maternity Cover

If your health insurance plan doesn’t offer coverage for maternity costs and the expenses pertaining to a newborn baby, then you can opt for a maternity add-on cover. As its name suggests, the maternity insurance provides you with financial assistance and covers the medical cost of pregnancy, delivery, and post-natal expenses. It may also include various vaccinations for the newborn. Most maternity covers come with a waiting period of two to four years after purchase. Therefore, you must plan for a child accordingly to enjoy extensive insurance coverage.

5. Waiting Period for Accidental Hospitalisation

There is no health insurance waiting period for medical treatment, including hospitalisation, that is required in the case of an accident. Therefore, you can enjoy coverage for accidental injury from the moment you purchase the policy.

6. Waiting Period for Psychiatric Ailments

As important as your physical health is, you should not underestimate the significance of your mental health. With the severe stress of the modern lifestyle, it is common for individuals to suffer from a wide gamut of psychiatric ailments. A majority of health insurance policies these days provide coverage for mental health-related expenses. However, such a cover can be opted for after the exhaustion of the waiting period applicable, which usually ranges between one to two years.

7. Waiting Period for Bariatric Surgery

Bariatric surgery is a procedure that makes changes to the digestive system to help with extreme obesity or weight-related issues. You can easily find health plans offering coverage for bariatric surgery, but a waiting period of one to two years is applicable.

Below are a few crucial details about the waiting period for health insurance that you must be aware of:

• It will not be referred to as a pre-existing disease if the insured receives a first-time diagnosis of a condition during the waiting period. In this scenario, the illness is covered by the coverage.

• There are numerous senior health insurance plans currently available that eliminate waiting periods by including a co-pay provision. A co-pay or co-payment provision suggests that the policyholders will be responsible for a portion of the claim costs while the insurance company will cover the balance. For instance, the policyholder would be responsible for paying ₹30,000 for a claim of ₹1 Lakh with a co-pay of 30%.

 

If you've been considering purchasing a health insurance plan, it might be wise to look into the one with the minimum waiting time.

As most health insurance policies come with a waiting period clause, there are only two circumstances under which no waiting period is applicable: 

• Emergency hospitalisation due to accidental injury

• Pre-existing disease coverage available from policy inception

 

In the event of an accident, the policyholder can opt for medical care and claim the expenses even during the initial waiting period. Similarly, if the health policy safeguards the insured against pre-existing ailments from day one of the plan, then the policyholder can get the benefits without any PED waiting period.

If you wish to get health insurance with a reduced waiting period, then you can do so by paying an additional premium. For instance, if you have a pre-existing ailment and wish to buy a health insurance policy with a reduced waiting period, then you can contact the insurer and pay an extra amount. The terms of the waiting period waiver also vary depending on the insurance provider you opt for.

 

Another instance in which the waiting period can be waived off is the conversion of a Group Health Insurance Policy into an Individual Health Insurance Plan. The Insurance Regulatory Development Authority of India (IRDAI) has stated that employees can convert their employer-issued Group Health Insurance Policy into an individual plan and get health insurance without a waiting period. This is because they would have already adhered to the terms of a health insurance waiting period while the policy was a Group Health Insurance Policy.

Here are some pointers about waiting periods in health insurance that you should keep in mind:

• First Diagnosis of an Ailment

If you get diagnosed with an illness for the first time after the purchase of a health insurance policy, then said ailment cannot be classified as a pre-existing ailment. Barring any specific exclusions in your health insurance plan, such an ailment shall be covered under the plan.

• Co-pay Clause

Several health insurance policies these days enable policyholders to get health insurance with no waiting period by introducing a copayment or co-pay clause. Such a clause entails that the insured shall have to bear a pre-decided percentage of the amount of a health insurance claim. This way, you can enjoy the benefits of health insurance without a waiting period. It is pivotal to check the terms of a health insurance policy to check the particulars of the co-payment clause.