Reclassify, Don't Exclude: A Policy Roadmap for IRDAI and Indian Insurers

India is witnessing a steady rise in chronic diseases such as Ankylosing Spondylitis (AS), Rheumatoid Arthritis (RA), diabetes, and hypertension. While medical advancements have made these conditions more manageable, health insurance underwriting often continues to treat all chronic diseases as permanent high-risk conditions. A more evidence-based approach can create a fairer and more sustainable insurance system.

Why the Current Approach Needs to Change

  • Many insurers continue to classify chronic diseases as pre-existing conditions, leading to:

    • Long waiting periods

    • Coverage exclusions

    • Higher premiums

    • Limited policy options

  • Patients with well-controlled conditions are often assessed the same way as those with active or uncontrolled disease, despite having different health risks.

The Growing Need for Reform

  • According to the Ministry of Health and Family Welfare, more than 8.64 crore people are currently receiving treatment for hypertension and diabetes under the National Programme for Prevention and Control of Non-Communicable Diseases (NP-NCD).

  • This highlights that chronic diseases affect a significant portion of the population and require insurance models that recognize effective disease management rather than focusing only on diagnosis.

A Policy Roadmap for IRDAI

1. Reclassify Based on Disease Control

  • Assess patients based on disease stability, treatment adherence, and clinical outcomes rather than diagnosis alone.

  • Differentiate between well-managed, moderately controlled, and uncontrolled conditions.

2. Promote Evidence-Based Underwriting

  • Consider objective health indicators such as:

    • Regular follow-ups with rheumatologist

    • Medication adherence

    • Hospitalization history

    • Disease activity and remission status

3. Reward Responsible Disease Management

  • Offer incentives for patients who effectively manage their condition, such as:

    • Reduced waiting periods

    • Fairer premiums

    • Better coverage options

    • Wellness benefits

4. Improve Transparency

  • Clearly explain:

    • Why a condition is classified as high risk

    • Waiting periods and exclusions

    • The medical criteria used during underwriting

IRDAI Is Already Moving Towards Inclusion

  • The IRDAI Master Circular on Health Insurance Products (2024) encourages insurers to offer products for people with pre-existing diseases and chronic conditions.

  • Building on this, insurers can adopt more personalized and evidence-based underwriting practices.

Source: https://irdai.gov.in/health-dept

Benefits of Reclassification

For Patients

  • Fairer access to health insurance

  • Lower financial burden

  • Better continuity of treatment

  • Increased confidence in long-term healthcare planning

For Insurers

  • More accurate risk assessment

  • Better customer retention

  • Improved trust and transparency

  • Reduced long-term claims through preventive care

Conclusion

The future of health insurance should be based on how well a chronic disease is managed, not simply on the presence of a diagnosis. By reclassifying rather than excluding people with chronic illnesses, IRDAI and Indian insurers can create a more inclusive, evidence-based, and sustainable health insurance system that benefits both policyholders and insurers.

Beyond policy reforms, patients also benefit from access to trusted communities where they can share experiences, learn about treatment options, and receive emotional support. Joining an Arthritis Support Network like Antardhwani can help individuals and caregivers better manage the challenges of living with chronic autoimmune diseases while fostering awareness and advocacy for equitable healthcare and insurance practices. 

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