For women living with PCOS, the condition can also have implications for health insurance, particularly when it comes to pre-existing disease waiting periods, medical disclosure, exclusions, outpatient care and maternity benefits.
A PCOS diagnosis does not automatically prevent a woman from buying health insurance. However, the way it is treated can vary depending on when the condition was diagnosed, the insurer’s underwriting framework, the applicant’s medical history and whether there are associated health conditions.
“PCOS should not be looked at as an automatic barrier to health insurance. What matters is the individual’s health profile and the insurer’s underwriting framework,” said Yogesh Agarwal, Founder and CEO, Onsurity, an Indian healthtech and employee benefits platform.
Arun Ramamurthy, Co-Founder of Staywell.health, an Indian AI-native retail health insurance distribution startup, said insurers may consider factors including the severity of PCOS, ongoing treatment, investigations, treatment history and associated diseases while assessing an applicant.
PCOS may be treated as a pre-existing condition
If PCOS was diagnosed before a health insurance policy was purchased, it may be considered a pre-existing disease (PED), subject to the policy terms and the applicable definition.
Vineet Gupta, Head – Product Development at ManipalCigna Health Insurance, a standalone health insurance company, said a waiting period may apply before PCOS-related hospitalisation or treatment is covered. Under current health insurance regulations, the maximum waiting period for pre-existing diseases cannot exceed 36 months, although individual products may have shorter periods.
Amol Sawai, SVP and National Product Head – A&H Underwriting at Liberty General Insurance, a private general insurance company, said PED waiting periods can range from 12 to 36 months depending on the insurer and plan.
The important distinction for policyholders is that a waiting period is different from a permanent exclusion.
Once the applicable waiting period has been completed, treatment remains subject to the policy’s other terms, exclusions and limits.
Does having PCOS mean paying more?
Not necessarily.
Sawai said premiums are unlikely to be significantly affected for a well-managed PCOS diagnosis, although associated conditions such as diabetes, obesity or cardiovascular risk factors may be considered during underwriting.
Ramamurthy said the impact can differ because PCOS can coexist with conditions such as insulin resistance, diabetes, obesity and fertility problems. The insurer may consider these separately depending on the product and the disclosures required.
Arti Mulik, Chief Technical Officer at Universal Sompo General Insurance, general insurance company, said more detailed underwriting may be required where PCOS co-exists with conditions such as obesity, insulin resistance, Type 2 diabetes, hypertension, infertility-related complications or cardiovascular risk factors.
Thus, the underwriting outcome is not determined by the PCOS diagnosis alone and can differ between applicants.
What should women disclose?
When purchasing health insurance, applicants should answer the medical questions in the proposal form accurately.
For someone with PCOS, this could include the diagnosis, relevant medication, consultations, investigations, previous treatment or hospitalisation and related medical conditions, depending on what the insurer asks.
“Disclose what is asked in the proposal form accurately,” said Agarwal. He said ongoing medication, previous treatment, investigations and relevant medical history should be stated clearly where applicable.
Choudhary, CEO of FatakSecure, the digital insurance arm and subsidiary of FatakPay, said applicants should disclose the diagnosis and when it was made, along with regular medication and other relevant medical history.
Ramamurthy said applicants should avoid making their own assessment about whether a condition is too minor to mention. The relevant information should be provided in response to the questions in the proposal form.
What can happen if PCOS is not disclosed?
Non-disclosure can become an issue when a claim is filed.
If an insurer finds that relevant medical information was withheld when the policy was purchased, it can examine whether the information was material to underwriting or the claim, subject to the policy terms and applicable regulations.
Choudhary said non-disclosure can result in disputes over claim admissibility and, depending on the circumstances, can have consequences for the policy as well.
This is why experts advise maintaining medical records and providing consistent information when purchasing insurance or completing subsequent underwriting processes.
Policyholders should also be aware of the 60-month moratorium period. After 60 continuous months of coverage, claims and policies generally cannot be contested on grounds of non-disclosure or misrepresentation, except in cases of established fraud, subject to the regulatory framework.
Agarwal said this provision should not be viewed as a reason to withhold information when purchasing a policy.
A diagnosis after buying the policy is different
The timing of the diagnosis can also affect how the condition is treated.
If PCOS is diagnosed after an existing health insurance policy has started, it is not automatically a pre-existing disease for that policy.
Choudhary also highlighted the distinction between routine renewal and fresh underwriting. Under IRDAI’s health insurance framework, an insurer cannot carry out fresh underwriting at renewal unless the policyholder seeks an increase in the sum insured. If the sum insured is increased, underwriting can be undertaken for the increased portion.
This makes it important to distinguish between continuing an existing policy and purchasing additional cover, such as a new policy or a top-up.
Fertility treatment may not be covered
One area requiring particular attention is fertility treatment.
PCOS can be associated with fertility problems, but health insurance coverage for PCOS does not automatically translate into coverage for infertility treatment or assisted reproductive procedures.
“Certain PCOS complications can lead to infertility, and most insurance policies don’t cover infertility treatments or cover them with sub-limits or only specific procedures,” Mulik said.
Sawai said women should specifically check whether fertility treatments, IVF, hormonal therapies and related procedures are covered or excluded under the policy.
Maternity cover should also be examined separately. It generally comes with its own waiting period, eligibility conditions, exclusions and coverage limits.
OPD cover can be relevant for PCOS
PCOS management can involve regular consultations, diagnostic tests and medication without requiring hospitalisation.
That makes outpatient or OPD coverage another feature worth checking.
Gupta said women should examine whether a policy provides OPD benefits because consultations, diagnostic tests and medicines may not be covered under a standard hospitalisation-focused policy unless OPD benefits are specifically included.
Sawai also advised women to evaluate OPD benefits when choosing a policy, particularly because PCOS management can involve continuing outpatient care.
The result is that two policies with the same headline sum insured can offer different levels of practical coverage for someone managing PCOS.