The definition of pre-existing disease in Indian insurance law is broader than most policyholders realise. You do not need a formal diagnosis for a condition to be treated as pre-existing.
What IRDAI Considers a Pre-Existing Disease
Under IRDAI regulations, a pre-existing disease is any condition diagnosed by a physician within 36 months before policy commencement, OR for which medical advice or treatment was received within 36 months before policy start. This means: if you visited a doctor, filled a prescription, or had any investigation done in the 3 years before buying your policy, that condition is pre-existing.
The Investigation Process During Claims
When you file a significant claim, insurers investigate your medical history including hospital records, pharmacy purchase databases, diagnostic lab records, and shared industry claim history databases.
After 5 Years of Continuous Coverage
After 60 continuous months of health insurance coverage, no insurer can reject a claim on grounds of non-disclosure, except in cases of established fraud. This is the Moratorium Period mandated by IRDAI.
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