Should you go for a medical test before buying a health insurance policy?, ET HealthWorld

New Delhi: While most health insurance companies do not enforce the requirement for policyholders to undergo a medical test before buying a health insurance policy, some companies may ask you to get one. Many people see these medical tests as a hassle and simply want to do away with having to schedule and undergo multiple check-ups. That’s why many people merely declare to the insurer if they have any known pre-existing ailments, and get the policy. In case of no known medical history, many people get the policy without declaring any pre-existing disease.

However, sometimes this may boomerang and your health insurance claim may get rejected by the insurance company on the grounds of non-declaration of pre-existing diseases. This is despite you filling out all the mandatory pre-existing disease declaration forms. Know why? Read on to learn more about navigating such conditions.

Will my claim be rejected due to a pre-existing disease I am unaware of?

Many diseases like diabetes and conditions of the heart, kidney, etc often go undiagnosed for years. They only surface when there is a lifestyle trigger, after which the individual’s health is never the same. So, what happens if the policyholder makes a claim related to a pre-existing condition that they have been previously unaware of?

Health insurance companies can take a divergent approach on this. While some insurers may not take any adverse action against the claim, others may go for greater scrutiny. Mahesh Yelapure, Head of Health Underwriting and Claims, Go Digit General Insurance, says that medical conditions that arise or are diagnosed after policy purchase are not classified as pre-existing diseases (PED).

A recent directive by Justice Sangita Dhingra Sehgal of the Delhi State Commission has stated, “until a person is hospitalised for a disease closer to the obtaining of an insurance policy or any disease for which he has never been hospitalised, that disease cannot be treated as a pre-existing disease”.

However, conditions that appear closer to the policy’s starting tenure may require thorough investigation at the claims stage and insurers may do their due diligence before approving the claim. And despite genuine reasons behind the non-disclosure of such conditions, insurance claims might also be rejected.

Shashi Kant Dahuja, Executive Director and Chief Underwriting Officer of Shriram General Insurance, says that while unintentional non-disclosure could happen due to a misunderstanding, lack of knowledge about the disease, or not fully understanding the disclosure requirements, it can still lead to claim rejection or policy cancellation, depending on the insurer’s policies and local regulations.

Should you insist on a medical checkup while buying a health insurance policy?

While most health insurers recommend taking a pre-policy medical test, very few insist prospective policyholders take one. Says Siddharth Singhal, Business Head – Health Insurance, Policybazaar.com, “For the last 4 years, especially post the Covid-19 pandemic, only about 0.5% of customers need to go through medical tests to get a health insurance policy.”.

Health insurance companies are not insisting on a medical checkup; however, given the risk of delay in claim processing or even rejection, it may be a better idea to ask the health insurance company for a medical checkup while buying a health insurance policy. This will remove any room for confusion regarding any PED.

What are some general medical tests insurers ask to undertake before granting the policy?

Sharad Mathur, MD & CEO of Universal Sompo General Insurance says that some of the tests undertaken during pre-policy medical checkups include Complete Blood Count (CBC), blood sugar (fasting and postprandial), lipid profile, liver and kidney function tests, ECG, chest X-ray, urine analysis, BMI, blood pressure monitoring, and HIV/Hepatitis screenings.

“For older applicants or high-value policies, additional tests like stress tests (TMT), lung function tests (spirometry), ultrasounds, and eye examinations may be required. Age-specific evaluations such as cognitive assessments and bone density tests are often included for senior citizens”, he notes.

Are diabetes and hypertension considered pre-existing diseases?

Remember that even after buying a policy, you may not be immediately eligible to make claims related to your pre-existing diseases. Most insurers consider conditions like diabetes, hypertension, asthma, heart disease, chronic kidney disease, asthma and thyroid disorders as pre-existing ailments.

Commonly, waiting periods for these ailments can range from 12 months to 36 months depending on the insurer and specific condition. In contrast, some conditions may allow for premium loading instead of waiting periods; this means that while coverage is provided immediately, the policyholder pays a higher premium due to their pre-existing condition.

Who bears the cost of pre-policy medical checkups?

Generally, if the insurance company agrees to give a policy to the individual, they fully bear the cost of all pre-policy medical tests. However, there are no standard rules regarding who pays if the individual is denied policy after the medical checkup.

In some cases, the insurer and individual may split the costs. Or else, some insurers may charge the entire cost back to the policyholder or deduct it from any refundable amount.

Per Parthanil Ghosh, Director & Chief Business Officer, HDFC ERGO General Insurance, “the cost of pre-policy medical check-up in case of non-issuance of policy is usually born by both insurer and insured equally. However, this depends on company’s product and underwriting policy”.

In other cases, the entire cost may be borne by the insurer themselves. According to Mathur, MD, “In most health insurance policies, if an individual undergoes a pre-policy medical test and fails, the cost of the medical examination is typically borne by the insurance company. This is because the test is part of the underwriting process initiated by the insurer. However, policies and practices may vary among insurers, and some might have clauses requiring the policyholder to bear the cost if the proposal is declined based on medical test results”.

• Published On Dec 31, 2024 at 06:43 AM IST

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