What Are the Different Types of Waiting Periods in a Health Insurance Policy?

1. A person falls ill due to dengue on the 7th day after buying the policy, gets hospitalised for 3 days, and submits a claim.
2. A person already had diabetes before buying the policy. Five months after purchasing the policy, he gets hospitalised for 7 days, and submits a claim.
3. A person gets operated on for cataracts in the fourth month after buying a policy and submits a claim.
4. A person makes a maternity claim in the second month after buying a policy.
5. A person gets diagnosed with cancer on the 25th day after buying a policy, gets hospitalised for 10 days, and submits a claim.

You may be surprised to know that all of the above claims will be rejected. The reason being: “waiting period”. There will be an exception if the waiting period is not applicable or has been waived. So, what is this waiting period, its types, and what else should you know about them? Let us discuss.

What Is a Waiting Period?

A waiting period is the specified period (days, months, or years) a policyholder must wait before they can make a claim for specified illness(es), treatments, procedures, etc. During the waiting period, the insurance company will not accept any claims unless the waiting period has any exception(s) or has been waived. The waiting period is also known as a cooling period.

Most health insurance policies come with various waiting periods. The duration of the waiting period, the related terms and conditions, the exceptions (if any), etc., are all stated in the health insurance policy document. The policyholder needs to know these waiting periods to understand when a claim can be made.

Types of Waiting Periods

Some of the waiting periods in a health insurance policy include the following.

1) Initial Waiting Period

Whenever you buy a new health insurance policy, there is a 30-day initial waiting period during which the claim will not be covered. The waiting period starts from the policy commencement date. The exception is a claim arising as a result of an accident. Accident related hospitalisation expenses are covered from Day 1.

There may be an instance when the insured goes for an enhanced sum assured after the policy commencement. In such a scenario, the 30-day waiting period will be applicable for the enhanced portion of the sum assured from the enhancement date.

2) Waiting Period for Pre-Existing Diseases (PED)

A pre-existing disease means any condition diagnosed within 48 months prior to the policy issue date. Claims related to any pre-existing diseases (PED) will be covered after the PED waiting period is over. The PED waiting period is usually 2 to 3 years.

Some companies may link the PED waiting period to the sum assured or the policy variant. For example, the PED waiting period maybe three years for a sum assured of up to Rs. 5 lakhs. The PED maybe two years for a sum assured of more than Rs. 5 lakhs. Similarly, the silver variant of the policy may have a PED waiting period of 3 years, and for the gold variant it may be two years.

Suppose you port a policy from insurance Company A to Company B. In this case, your continuous coverage with Company A will be counted towards applying the PED waiting period with Company B. For example, assume that Company B has a PED waiting period of 3 years. You had continuous 2 years of coverage with Company A. After 2 years, you ported to Company B. In this case, your waiting period with Company B will be only 1 year (Company B’s PED waiting period of 3 years – Company A’s 2 years of continuous coverage).

In a customer-friendly move, from 1st April 2024, IRDAI has reduced the maximum PED waiting period from 4 years to 3 years.

3) Waiting Period for Specific Diseases/Procedures

There is a waiting period for treating specified diseases or performing specified procedures. Some of these include:

1. Cataract
2. Hysterectomy
3. Knee replacement surgery, joint replacement surgery, vertebrae disorders
4. Varicose veins
5. Stones in urinary uro-genital and biliary systems
6. Fissures, fistula in the anus, piles, all types of hernia, haemorrhoids
7. Sinusitis and related disorders, surgery on tonsils, any benign ear, nose and throat disorder or surgery
8. Gastric and duodenal ulcers, any type of cysts/nodules/polyps/internal tumours/skin tumours, and any type of breast lumps (unless malignant), polycystic ovarian diseases
9. Any surgery of the genito-urinary system, unless necessitated by malignancy
   

(Source: Manipalcigna)

The above list is not exhaustive. For the complete list, refer to your policy document or contact your insurance company.

The treatment for the above diseases or procedures usually has a waiting period of two years. Even if the specified disease is diagnosed after buying the health insurance plan, still the waiting period will apply from the policy commencement date.

If any of the specified diseases are pre-existing at the time of buying the policy, the pre-existing waiting period will apply.

4)  Maternity Waiting Period

Maternity coverage involves hospitalisation expenses related to childbirth. Usually, maternity coverage has a waiting period ranging from 9 to 36 months.

5)  Critical Illness Add-on Cover Waiting Period

There is a 90-day waiting period during which the claim for critical illnesses will not be covered. The waiting period starts from the policy commencement date. It applies to any critical illness add-on benefit that has been opted for.

6)  Other Waiting Periods

Apart from the five waiting periods discussed in the above section, a health insurance policy may have other waiting periods. Some of these include a waiting period for covering psychiatric health conditions, bariatric surgery, Covid-19 coverage, newborn baby inclusion, etc.

Points to Note About Waiting Periods

1. The IRDAI defines the maximum waiting period for each category. The insurance company can offer a lower waiting period or waive it for its customers.
2. When a policy is ported from one insurer to another, you can carry forward the waiting period benefits.
3. Different products of the same insurer can have different waiting periods for the same category.
4. Different variants of the same product can have different waiting periods for the same category.
5. Some insurance companies can give you the option to reduce the waiting period for a category on payment of an extra premium.
6. Usually, there are no waiting periods in corporate health insurance plans.

Waiting Periods Are Included to Protect the Interests of All Policyholders

You must be wondering why waiting periods are included. They are included so that some people with dubious intentions don't take advantage of the system. In the absence of waiting periods, a person who has diabetes and requires frequent hospitalisation, will buy a policy and abuse it. Similarly, a person can purchase a policy during pregnancy and claim its benefits. It will make the whole model of insurance unsustainable. Hence, waiting periods are included in health insurance policies to protect the interests of all policyholders.

Reference:  Manipalcigna