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Health Insurance Cover for Congenital Diseases in India

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Want higher protection from rising medical inflation? Want to be worry-free about the changing healthcare dynamic and save a ton of money? All you need to do is to opt for proper health insurance for yourself and your family. Beneficial health insurance saves you from the hassles of spending your entire savings on medical bills. 

Be it regular health insurance or critical illness insurance, you can purchase it from the top health insurance companies available in India. Also, if you are confused about which medical insurance cover you should opt for congenital diseases, then keep reading!

What are Congenital Diseases?

Diseases that a person is born with are referred to as congenital diseases. They are birth defects that form during a baby’s intrauterine life. They can be structural or functional. Furthermore, they are also referred to as congenital anomalies or genetic disorders, and they can be found before birth, at birth, or during the early years of life.

Congenital anomalies in infants can be caused by a wide range of factors, including genetic mutations, environmental factors, maternal age, nutritional status, infections, and socioeconomic factors.

India has around 1.7 million people with congenital diseases, which is around 6-7 per cent of the total population, according to a joint report by WHO and MOD in 2016. Although internal congenital disorders are not easily visible, external congenital anomalies can be quickly identified. Even so, babies with congenital disorders may suffer from health problems or disabilities for their entire lives. This can be prevented by critical illness insurance.

Are Congenital Diseases Covered by Health Insurance Plans in India?

Yes. A 2019 IRDAI (Insurance Regulatory & Development Authority of India) guideline mandates that congenital diseases are covered by all regular health insurance plans in India.

They cover the costs of in-patient hospitalization, daycare procedures, surgeries, pre-hospitalization, post-hospitalization, and other medical expenses related to the diagnosis and treatment of congenital diseases. The coverage amount can be anywhere between Rs. 50,000 and Rs. 6 crores. However, the extent of coverage and the amount of coverage depend on the health insurance policy you have chosen. The majority of the health insurance companies provide benefit plans for the customers. 

However, not all congenital illnesses in India are covered by health insurance plans. Only internal congenital diseases are covered by standard health insurance plans, in accordance with IRDAI guidelines. The insurance provider is not obligated to pay for treatment costs if a person has an external congenital disease.

Waiting Period to Cover Congenital Diseases by Health Insurance Plans

Although internal congenital diseases are covered by health insurance plans in India, you cannot use the coverage until the waiting period has passed. After a 2-year waiting period, congenital diseases are typically covered by health insurance policies.

This means that it will take two renewals in a row before you can make a claim for congenital diseases under your health insurance. You can easily get your health insurance companies to cover the costs of treating internal congenital diseases once the waiting period is over.

However, the 2-year waiting period for congenital anomalies only applies if your child is found to have the condition after you have bought the health insurance. If your child was identified as having an internal congenital disorder prior to the time you bought the policy, it will be regarded as a pre-existing condition. 

Then you won’t be able to submit a claim for congenital diseases under your policy for up to four renewals. This is due to a 2-4 year waiting period before all pre-existing conditions are covered by health insurance companies.

Check your health insurance companies documents carefully to determine the precise waiting period for congenital diseases and pre-existing conditions.


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