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Do I declare my artificial tooth as Pre Existing Disease

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17 Sep, 2020 by  Chetan

I have an artificial tooth and 2 cap on teeth since 8 years. It is normal working.Do I declare these as pre existing condition in health policy? There is very less clarity on PED on any insurance provider website. Also not many state clear answer on queries asked.

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Health Insurance

3 Answer

17 Sep, 2020

Hey Chetan,

I will simplify it for you.

What is a Pre-Existing Disease (PED)?

On the day that you buy new health insurance, or increase your sum insured in an existing health policy or port your existing policy to a new insurer, whatever medical history is known to you, you must mention that in the proposal form or renewal form. Notice the emphasis on the underlined words.

So what is the medical history that one should mention?

In the last 4 years, I have seen more than 500 claims rejected due to non-disclosure of PEDs. Based on my experience as a Claims expert, I classify PEDs into 5 categories:

(1) Any hospital admission or surgeries since birth - Yes, since birth! For examples, new borns have surgeries for club foot which one forgets over time. There are several small or big surgeries for hernia, piles, varicose veins, cardiac arrest, kidney stone, uterus removal, accidents & injuries etc that happen. Also, there could be admissions for fevers, headaches, jaundice etc. All of these MUST be declared. No information is small for insurer.

(2) Any consultations done with doctors, not leading to hospitalization, since birth - Yes, again, since birth! Clients tell me, they had mild BP or sugar and it corrected on its own, or they had some skin disease, or they consulted doctor some something and took medicine for a while and it all became fine. Some people are still on medications for BP or sugar or thyroid or migraine. Some have early onset of arthritis. Whatever your doctor tells you, you must tell insurer.

(3) Any accidents since birth, not leading to hospitalization - We have big or small accidents or injuries or falls while growing up or as adults. My dad once fell from his scooter and fell unconscious for a moment. His head scan after almost 2 decades of that accident still show a hairline fracture in his skull. But he never met a doctor after that accident. A friend of mine had several falls during his adult years and he lost 2-3 teeth during those adventures. Nothing should be missed in disclosure.

(4) Any continuous, infrequent or seasonal allergies - Some people suffer from Asthma during specific seasons. Some have the condition all round the year. People have skin allergies or allergies related to some foods. Never miss to declare any of it in proposal forms.

(5) Any infrequent or regular pain in any parts of the body - I have known people who have had joint pains for years and they manage that using home-made solutions. It could be the onset of Arthritis. Who knows? People have random headaches for several weeks in the past, it comes and it goes. It could be migraine, or worst, it could turn out to be tumour. Ofcourse, for this category of issues, people don't consult doctors and manage on their own till one day they get diagnosed. Please remember, this one does not count in non-disclosure, but in my experience, I have seen insurers enforcing PED waiting period of 4 years when it is found the policyholder had such pains prior to policy inception date. And yeah, this is a bit random.

Am I overdoing it?

No way. You should see insurers and TPAs overdo claim rejections due to slight non-disclosures. Better be tight when filling proposal form.

What if I don't disclose?

When non-disclosure is found at the time of claim (trust me, they will find it out), firstly the insurer rejects your claim. Even if the undisclosed medical condition has nothing to do with the medical problem for which the current claim is filed, insurer WILL reject your claim. In extreme cases, where the PED falls in the declined risk category, insurer simply rejects the policy. YES sir. Policy is rejected, insurer keeps all the past premium. No refunds. All the money... GONE!

What if insurer rejects my proposal if I disclose PED?

That is the purpose of declaration. Insurance company has no obligation to give you policy. Think about it. For a small amount like 5-10k, insurer is taking a massive risk of 3-5 lakhs by giving you policy. But here's the silver lining - Different insurers have varied underwriting protocols. It means, to one insurer you are a risky customer, to another insurer, you are perrrrfect!! So don't lose hope. Knock other doors if one closes.

My agent is telling me to not mention PED in the form

Donate your premium, because anyways your claim and policy will get rejected in future. Why buy insurance then? All these guys who sell you insurance - agents, call center guys from price-comparison websites... even tele-agents from insurers... they're idiots. Yes I said it, they're idiots. They're never there when your claim or policy gets rejected. Take matters in your hand.

So yeah, sorry. Long answer to your short question Chetan. Declare anything and everything.

Happy to answer if you have any followup question.

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17 Sep, 2020
Hi Sir, that answer was really helpful. Makes it absolutely clear. I've only recently discovered this platform and it's a blessing for all those who ask for genuine advice. Thank you! As a follow up to my previous question wanted to ask you, what should one do if they do not remember exact timelines of treatment/hospitalisation for fever, diarrhoea, abdominal pain,etc that was done maybe around 15-16 years ago? I know many people just cannot recall all their hospitalisation month/years or the exact reasons for hospitalisation after it is many years past it. How do they declare in such cases? I've trying to help my family/friends with this and have come across many such cases where the treatment history is vaguely remembered by them. Hence wanted your opinion on it. Thanks a lot.
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19 Feb, 2021
Manjunath Prasad
1. I have seen many policies clearly define pre existing disease as the one which you diagnosed/consulted/etc. only in the last 4 years. So, if I had a condition and got cured before 4 years, ideally I don't need to declare, right? So, don't you think, declaring something that was cured like long long back is not essential? If it later becomes a dispute, don't you think IRDA will favor the Customer purely based on the definition of the pre-existing disease. 2. Don't you think overdoing in terms of disclosure may lead to rejection that will lead to more rejections given that you need to declare the previous policy rejections making the exercise counter productive. While its true that different companies are differently risk averse, I feel that as a business, they would rather find another customer for 5k premium instead of a risk of losing lakhs. 3. Recently PED definition got changed. IRDA guidelines say only those which have been consulted in the last 4 yrs can be termed as Preexisiting. Is this amendment optional or is enforced. Please review how this amendment works out. 4. An year back, I increased Sum insured for Super topup during Renewal with HDFC ERGO, an year after a minor surgery which was paid by Base policy of Religare. During Sum Insured increase procedure, they just sent a separate payment link with Insured amount. HDFC didn't ask for any disclosure. I even called the customer care if I have to disclose afresh of any recent developments. They said its not necessary, normal waiting period may apply for the increased insured amount. Please be aware that this is the general customer care department I talked to, not the underwriting/medical team. So, what may wrong now? Should I inform them now ? 4. You mentioned that the company will somehow find out. Can you tell me how exactly, when there's no information trail whatsoever. Its not like its linked to some PAN Card that they would have all the financial info, right? I am curious. Please shed some light. 5. Based on experience, please name a few companies which accept policies more readily with/without premium loading.
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17 Sep, 2020

Pre-existing conditions refer to conditions that are long term, permanent or "chronic" in nature, requiring medicines, regular treatment and might affect treatment during hospitalization. Any condition, ailment or injury or related condition for which the insured had signs or symptoms, and/or was diagnosed and/or received medical advice/treatment, prior to the inception of the first policy

Examples include diabetes, asthma, high cholesterol, high BP, any handicap, COPD, tumour, heart/kidney conditions, athritis . You should also declare any surgery, hospitalization or any treatment requiring you to take medicine regularly for more than a week.

Information on pre-existing condition is kept vague by health insurers so that customers end up declaring anything of consequence. It is generally a good practice to declare "anything" that might be related to health or affecting treatment.

Generally, unless dental procedures are covered in the health policy, declaring these two specific conditions may not be needed.

Specifically, when Health insurers ask for pre-existing conditions, they typically mean (this is not a comprehensive list)

1) cancer/ tumour

2) kidney related issues

3) disorders of heart

4) liver issues

5) diabetes, hypertension, hyperlipemia

6) lungs disorders, asthma

7) athritis

8) COPD, apnea

9) genetic disorders, handicaps

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17 Sep, 2020
Having said that, safer to declare them in the form... :)
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17 Sep, 2020

Happy to know Chetan you found the information useful.

Let me address your doubt.

What to do when we don't remember exact details of PED?

Let me tell you something interesting from experience of having spoken to thousands of patients.

At the time we consult a doctor or when we admit in hospital and are asked about our medical history, we share a fuzzy background of past episodes. Doctors make a note of all those details.

Consider insurance to be no different. Whatever you can remember, mention in proposal form.

What I advise clients is that they should try to remember any life events that happened before or after or during that medical episode. It can help you narrow down the timelines. If you ask me what I prefer, I like if we can estimate history to the exact month and year. But it is wishful thinking. So whatever comes to memory, that's okay.

Problem of self-diagnosis

While you try to fetch the PEDs deep down from your memory, I would like to warn against a mistake some people make. Let me explain using a real life case.

I had a client who mentioned she has Arthritis for past 10 yrs. I probed, what treatment do you take. She replied, it's just the regular oil massage. I followed-up, asking who diagnosed her and what was the initial treatment given. She said she has never consulted an orthopedic dr. I was confused, so asked, then how do you know you have Arthritis. She revealed, her sister also has similar joint pain and she had consulted an orthopedic who said she has Arthritis. So she believes, since she has joint pain similar to her sis, she's too having same medical condition.

I wish people also realise that PED is a PED only if diagnosed by a valid medical professional. A doctor has to put a name to your problem. Only then it is a diagnosis. Otherwise those symptoms are of unknown origin.

I hope this helps Chetan.

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17 Sep, 2020
It did sir. Thanks a ton!
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