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Cover Crumbles On Fake Comorbidity Papers

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Cover Crumbles On Fake Comorbidity Papers
Dr Sudha Reddy - 01 May 2021

The astronomical rise in healthcare costs, medical inflation and high Covid-19 treatment costs at private hospitals, along with increased awareness, has changed people’s perception of health insurance.

A health insurance typically covers the medical expenses of an individual that may occur due to ill health. The coverage and premium differ across policies depending on factors like lifestyle choices and pre-existing medical conditions.

For all health insurance, it is mandatory to submit the medical history and mention the lifestyle choices like smoking and alcohol consumption that can lead to medical conditions. One’s medical history is of utmost importance while availing of health insurance.

Pre-existing illnesses are medical conditions that a person suffers from even before buying the policy. This is one of the most important factors to decide what kind of policy would be suitable, what would be the waiting period before such illnesses can be covered, and what could be the premium for the policy.

With the Covid-19 crisis turning uglier by the day, the disclosure of pre-existing diseases becomes even more important in case of health insurance. When discovered, such issues crop up as comorbidity factors and the health cover suffers major dents.

The Covid vaccination is definitely a ray of hope. Understandably, everyone wants to get vaccinated at the earliest to protect themselves and their loved ones from the virus. And due to this there are some cases where people might have shown comorbidities that were not present. As an insurer, we would not advise to do this, as it is ethically and legally incorrect.

As of now, insurance companies do not have access to the vaccination data of the government but in future, if the data is made available in case insurers start covering vaccination costs, it might lead to a rejection of the claim for the policyholder.

We always stress on how important it is to be honest about your comorbidities and your pre-existing diseases with your insurer. This not only increases your chances to have your claim approved but also lets the insurer suggest the right benefits so that they offer a policy tailored to the policyholder’s needs. Hence, in such a case, a fake comorbidity certificate might also land you in trouble later as it is data fudging and might impact claim settlements in a later date. Some states like Odisha have also issued warnings against the same, with serious implications if found out.

This also creates a higher demand in the market than anticipated and can cause a shortage of supplies for the more vulnerable section of the society. The government is systematically planning the entire vaccination drive to cover as many people as possible, giving priority to the more vulnerable section of the society first like the frontline workers, doctors, healthcare personnel, senior citizens and people with comorbidities.

In such a case, the supply of the vaccination is planned accordingly as well. With more people faking comorbidity certificates, there may be a sudden scarcity of vaccine, leaving the vulnerable section unprotected. Although now the good news is that people above 18 years can start getting vaccinated since May 1, leaving us with the hope of fighting Covid-19 indomitably.

One should know about the following pre-existing conditions while taking out a health insurance policy:

  • The need and type of health cover will differ from one another, and the terms and conditions concerning pre-existing conditions will also change depending on the medical history.
  • Not all ailments or illnesses are considered as pre-existing diseases or PED. Hence, it is important to check the list of PED that is covered in your health insurance policy. Generally, medical conditions that have a long-term effect on a person’s health are considered by insurers as pre-existing illnesses. For instance, minor ailments and their side effects, like cough, cold and fever do not determine a person’s health and hence are not categorised as PED.
  • Hiding pre-existing conditions can be a big mistake. One might think mentioning pre-existing medical conditions can lead to not getting health insurance. But, hiding the facts might hinder the chances of the claim and can lead to it being rejected. It is always better to disclose a pre-existing illness right at the start even if it may show a higher premium as what matters is the coverage of the policy.
  • The waiting period or the time for which you will have to wait for pre-existing conditions to be covered by your insurer is critical, and hence it needs to be rechecked before taking any policy. Generally, all insurance has a waiting period of 30-90 days before it is active, but when it comes to pre-existing diseases, there is a 2-4 year waiting period before the pre-existing condition is covered. The waiting period depends on the age, and what the condition is. While the policy will not cover your pre-existing illness during the waiting period, it will cover other ailments and injuries.
  • One can also get a pre-existing disease waiver or pre-existing disease exclusion. Availing of a pre-existing disease waiver would mean that the policy will not cover anything other than the pre-existing disease under the insurance policy. On the other hand, the pre-existing disease exclusion implies that the policy will cover everything other than the pre-existing disease.

So, while taking a health insurance policy, remember to disclose all the pre-existing conditions to the health insurer. Because not disclosing the condition can lead to claim rejection but if one takes a benefit that covers them like a waiver of pre-existing condition, the pre-existing condition also gets covered.

Also, in case one plans to change the insurance provider, they do not have to go through the pre-existing condition waiting period all over again. The Insurance Regulatory and Development Authority (IRDAI) has  approved health insurance portability by which the insured can carry it forward from one provider to another and once all waiting periods have been exhausted with one insurer, the insured need not endure it again.

Before purchasing the insurance policy, find out how long each of these waiting periods are for pre-existing coverage. Different insurance providers offer numerous choices of coverage with waiting period as short as day one coverage to four years in some cases.

You may wonder if it is worth declaring pre-existing conditions in the first place. But it is a wise choice to be as transparent as possible and declare the medical conditions so that one does not have to face any complications when claiming as insurers will verify if the declared information’s are true.


The author is the Head of Health and Travel at Digit Insurance

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