Congenital Diseases and Health Insurance


Early this year, Pooja and Roshan Bhandari were blessed with a beautiful baby boy. Sadly, the little one was born with a hole in the heart and needed to undergo surgery within a year to repair the defect. This abnormality failed to appear in the tests that Pooja underwent during her pregnancy. The parents were heartbroken, yet determined to protect their son at any cost. The parents had no choice but to pay for it out-of-pocket, which left a serious dent in their personal savings since they had not taken a health insurance policy that covered congenital anomalies. Having learnt their lesson, the couple now advises all their friends who are planning for a baby, to seek complete information on coverage of infantile conditions in their own health plans.

In earlier years, many health plans did not cover congenital anomalies.  However, recently the regulator (IRDAI) has mandated that these need to be addressed by insurers.

What are Congenital Disorders?

Congenital anomalies are medical conditions, often inherited, that occur on or before the baby's birth. These birth defects can be genetic in nature, and the risk is higher in families with a history of such disorders. In some cases it can occur during the foetus' developmental phase in the womb, perhaps due to exposure to toxins ingested by the mother. Such abnormalities range from mild to life-stunting to life-threatening, depending upon severity.

Types and categories of congenital disorders: Birth defects are either internal or external in nature. Internal defects materialize inside the body and can be detected only by specific screenings or medical tests. External defects occur on the surface and are visible to the naked eye.

Which ones are included/excluded in Health Insurance policies?

While internal congenital anomalies are included in health insurance policies, external congenital anomalies are not covered. Expenses towards correction of internal anomalies will be covered, if and only if they are discovered after the child is covered under the health insurance policies.  There may be a waiting period of 24 to 48 months from the start of the policy, before these anomalies are covered.

If during pregnancy, some congenital anomalies are discovered and there is treatment given, then insurers may consider compensation for the treatment. However, for this you have to have a maternity cover in place and expenses would be part of maternity expenses. One must understand that till the child is born, the child is a part of the mother and a single entity with the mother.  Therefore, covers and limits during pregnancy are for the mother. Once a child is born, a new entity is born and needs to be covered for health insurance independently.

If you already have a health plan, do check if it includes maternity cover and congenital anomalies. Else, this is another strong reason why you should opt for a comprehensive health plan, and opt for it early!

As Mrs. & Mr. Bhandari insist, it is most advisable that you seek all the relevant information about the terms and conditions governing your existing or proposed health insurance policy.

What should you look for?

  1. Waiting periods for Pre-existing conditions.
  2. Waiting periods for undiscovered ailments or specified diseases, specifically congenital defects for your baby, and others for both you and your partner
  3. Wide hospital network covering maximum hospitals in and around your residence for easy access
  4. Additional benefits such as ambulance cost, doctor consultations, health check-ups etc., either free of cost or at a nominal price
  5. Sufficient Sum Assured that will cover expected medical costs for treatment for the couple and the infant
  6. Comparatively higher premium: Be aware that the premium could be higher than usual for extra coverage, but it is absolutely worth it to protect your little one's health and future wellbeing. can guide you with all the pertinent information required to finalize the best health insurance plan, to protect your child's health and welfare. A little effort on your part will go a long way for your little one! All you need to do is log on to, enter some standard information, and soon after you will be contacted by a Sana Expert.

Wish you a healthy and happy life!

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