Rajesh bought a family floater health insurance policy with a sum assured of Rs. 10 lakhs. The policy covered Rajesh, his spouse, and his 2 children. Six months after buying the policy, Rajesh’s wife had to undergo a cataract operation. Rajesh filed a claim for Rs. 25,000, but the health insurance company rejected it. The reason given was the waiting period for specific diseases / procedures. Like Rajesh, if you don’t want to face any claim rejections, you must be aware of the various waiting periods in a health insurance policy. In this article, we will understand what a waiting period is in a health insurance policy and its types.
What is a waiting period?
A waiting period in a health insurance policy is the specified time period during which the insured person cannot make a claim. If a claim is made, the health insurance company will reject it. So, if the insured person is hospitalised during the waiting period, they have to pay the hospital bill from their own pocket.
The waiting period can apply to the entire health insurance policy or to specified illness/illnesses or medical procedure(s). The waiting period is the fixed time an insurance company requires you to wait before the insurance coverage starts, either for the entire policy or the specified illness(es) / procedure(s).
The waiting period for the same illness can differ across policies of different insurance companies, or among different policies of the same insurance company or among different variants of the same insurance policy. To understand the applicable waiting periods, you must read your policy document
Why does a waiting period exist?
The waiting periods in a health insurance policy act as a risk management tool for the insurance company. The waiting periods prevent the misuse of the policy benefits by the insured person. For example, suppose an individual is diagnosed with an illness, and the doctor advises a specified medical procedure within the next couple of months. What if the individual buys a health insurance policy after the diagnosis and uses it for treatment?
The waiting period prevents the individual from using the policy benefits for treatment of an existing illness. Similarly, there are other waiting periods in a health insurance policy. Let us understand them.
Types of waiting periods
Some of the waiting periods included in a health insurance policy are as follows.
Initial waiting period
The initial waiting period is usually applicable to individual and family floater health insurance plans. The initial waiting period is usually 30 days, starting on the date the insurance policy is purchased.
During the initial waiting period, the insured person cannot file any claim. Even if they do, the insurance company will reject the claim. The hospitalisation bill will have to be paid by the individual from their own pocket. The only exception to this is hospitalisation due to an accident, which is covered from Day 1.
The initial waiting period is included to prevent the misuse of a health insurance policy. It should not happen that an individual buys a health insurance policy with the intention of using it immediately after its purchase.
Pre-existing illness waiting period
If an individual is suffering from an existing illness at the time of buying a health insurance policy, they need to declare it. The insurance company includes such an illness under ‘pre-existing illness’. The waiting period for pre-existing illnesses is usually 12 to 36 months. During this period, the insured person will not be able to make a claim related to a pre-existing illness.
Some examples of pre-existing illnesses can include hypertension, diabetes, etc. Once the pre-existing illness waiting period is over, claims related to the pre-existing illness are covered. The pre-existing illness waiting period varies among plans of insurance companies and within plans of the same insurance company.
Specified illness waiting period
Under this category, the health insurance company lists certain illnesses / medical procedures for which a claim can be made only after the specified waiting period is completed. The waiting period for the specified illnesses is usually two years.
Some of the specified illnesses / medical procedures under this category include:
- Cataract
- Specified ENT disorders
- Varicose veins of the lower extremities
- Pancreatitis and stones in the urinary system
- Hemorrhoids, fissure or fistula of the anal region
- Hernia
- Spinal disorders
- Fibroids, PCOD, hysterectomy
- Specified gynecological treatments
- Joint replacement surgery
- Chronic kidney disease and failure
- Hyperplasia of prostrate
- Osteoporosis etc.
Maternity waiting period
The maternity coverage includes hospitalisation expenses related to childbirth. It covers normal and caesarean delivery. The maternity waiting period is usually 9 to 36 months.
Critical illness waiting period
There is usually a 90-day waiting period to cover any hospitalisation expenses related to a critical illness. Also, the insured person must survive for at least 30 days after the diagnosis of a critical illness.
Scenarios where waiting periods don’t apply
In employer-sponsored group health insurance plans, the waiting periods usually don’t apply. It means the employee gets full coverage right from Day 1. When an individual ports a health insurance policy from one insurer to another, they are usually allowed to carry forward the waiting periods that have already been completed with the earlier insurer.
How to manage waiting periods better?
You can take the following steps to better manage waiting periods.
- Buy a health insurance plan early in life. It ensures that most waiting periods for illnesses / medical procedures are already over by the time the need arises.
- Continue your health insurance policy without any breaks. Continuous coverage ensures the waiting periods are not reset to 0.
- When choosing a health insurance plan, look for one with either no waiting periods or the lowest possible waiting periods.
Read your policy document for waiting periods
Just buying a health insurance policy doesn’t mean your job is over. You must read the policy document carefully. Check the various waiting periods and their terms and conditions. Understanding the policy terms will help you make the most of your health insurance policy and avoid claim rejections and disappointment.
