Pre-Policy Medical Check-ups in Health Insurance

What is a Pre-policy Medical Check-up in Health Insurance?

The pre-policy medical check-up is a health examination that some insurance companies require applicants to undergo before issuing a health insurance policy. It helps the insurer assess a person's current health status, identify any pre-existing medical conditions, and evaluate the risk involved in providing medical coverage.

These tests are generally required for health insurance applicants above the age of 45 years or 60 years, depending upon the insurer and for those opting for a high sum insured. Moreover, the medical tests usually involve basic health assessments like ECG, blood serum test, blood pressure measurement, complete blood count, lipid profile test, blood sugar, etc., and may vary from insurer to insurer.

Why are Pre-policy Medical Tests Important in Health Insurance?

Take a look at some of the reasons that make pre-policy health check-ups important in mediclaim insurance:

• Ensures the Right Coverage: Pre-policy medical tests help insurance companies assess an individual's health condition and offer a plan that best suits their health needs.
• Identifies Hidden Health Issues: Many health conditions, such as high blood pressure, diabetes, or early-stage heart disease, do not show obvious symptoms. A pre-policy medical test can help detect such hidden health issues at an early stage, allowing people to take preventive measures and manage their health better.
• Prevent Claim Rejection: With the pre-policy test, transparency can be maintained in terms of any pre-existing diseases (PEDs), which further helps the insured in getting the claim settled without any rejection.
• Determines Premium Amount: Health insurance premiums are calculated based on the applicant's health risks. A healthy person is considered low-risk and may receive a lower premium, whereas someone with medical conditions might have to pay a higher premium.
• Helps in Customising Policies: Insurers can use medical test results to customise policies according to applicant's health conditions. For example, if a person has a high risk of critical illnesses, the insurer may suggest additional riders or a separate critical illness cover for better protection. This ensures that the applicant get coverage that aligns with their medical needs, rather than a standard plan that may not provide adequate financial support during emergencies.
• Peace of Mind: A pre-policy medical test provides clarity and peace of mind to the policyholder. Knowing that the policy is issued based on accurate health data ensures there are no surprises later in terms of health insurance claim rejections or coverage limitations.

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Common Scenarios Requiring Medical Check-Ups

Listed below are the common scenarios where pre-policy medical check-ups are required:

• Age Factor: Typically required for individuals aged above 45 years or 60 years, which may vary between insurers.
• Sum Insured: Mandated for mediclaim insurance plans with high sum insured amount.
• Health Risks: Necessary for individuals with pre-existing health conditions or a medical history.

Who Pays the Pre-policy Medical Test Expenses?

As per the directive of the Insurance Regulatory and Development Authority of India (IRDAI), half of the medical test expenses need to be borne by health insurance companies, and the remaining balance needs to be paid by the applicant.

In fact, some insurance providers cover the full cost of pre-policy medical tests, especially if they are done at their network diagnostic centre. However, in some cases, applicants may need to pay for these tests upfront, and the amount is later reimbursed on the issuance of the policy.

NOTE: The cost of pre-policy medical check-ups can differ based on the hospital and location; therefore, it is best to check with the insurance provider for exact details.

Results of Pre-policy Medical Tests in Health Insurance

After the pre-medical test reports are received, the health insurance provider will decide whether or not to provide coverage within the terms mentioned in the policy document. In case the conducted tests show an ailment or a certain medical condition, the health insurance company can then opt for the following options:

• Rejection: In case the illness is at high risk or will require frequent visits to the hospitals for the treatment, then the insurer might choose to reject the proposed mediclaim insurance application.
• Higher Premium: The health insurance company would issue the policy and provide coverage to the policyholder in exchange for a higher health insurance premium.
• Exclusions: The health insurance provider might choose to issue the policy ; however, would exclude coverage for the detected medical conditions or illness. This is mostly done when the provider deems the medical condition too risky to be covered.