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Does Health Insurance Cover Congenital Diseases in India?

Updated On Sep 06, 2023

Living a healthy lifestyle is the best way to stay disease-free. Healthy eating, 8 hours of sleep a day, and regular exercise are all part of it. While maintaining a healthy lifestyle, people with congenital diseases still appear to acquire problems. It is a problem that is present in newborns at birth. These illnesses potentially have high treatment expenses. Health insurance generally enables us to manage the financial implications of medical risks. But what about an inherited condition like a congenital disease? Is it covered under health insurance plans? Let us find out and gain more knowledge about these disorders.

Congenital Diseases: An Overview

A congenital disorder or disease is a condition a person may acquire at birth. A World Health Organisation (WHO) research estimates that 6% of newborns worldwide develop congenital diseases. Environmental triggers or hereditary conditions cause them. Some common causes include genetic mutations, maternal age, environmental factors, dietary habits, infections, and socioeconomic issues. According to a WHO report, congenital diseases are to blame for the deaths of more than 170,000 children under five years.

Congenital Diseases and its Types

Congenital anomalies are typically of two types: internal and external. Internal disorders are typically hard to observe. External ones, however, could be easier to spot.

The following list includes common congenital illnesses in India:

  • Down syndrome
  • Congenital heart disease
  • Congenital hypothyroidism
  • Cleft lip and cleft palate
  • Cystic fibrosis
  • Cerebral palsy
  • Sickle cell disorder
  • Club foot
  • Spina bifida
  • Fragile X syndrome
  • Edward's syndrome
  • Phenylketonuria
  • Thalassaemia

Does health insurance cover congenital diseases in India

Health Insurance Coverage for Congenital Diseases

It is understandable to worry that your child might get a congenital disease if someone in the family has previous experience. You can screen the disorders before birth. Additionally, therapies are available to lessen the likelihood of a congenital condition. According to the Insurance Regulatory and Development Authority of India (IRDAI)'s 2019 guidelines, these diseases should be covered by all insurance plans. Therefore, internal congenital disorders like cystic fibrosis and heart disease are generally available in insurance coverage.

A health insurance policy may cover costs associated with diagnostic procedures, hospitalization, therapy, etc. Additionally, the sum could vary from Rs 50,000 to Rs 6 crores. However, not all congenital illnesses in India come under health insurance coverage. The insurance provider is not required to cover the cost of therapy if a person has an external condition. Additionally, most health insurance policies often include a 12- to 48-month waiting period before you may submit a claim.

Waiting Period For Congentital Diseases Health Insurance

The waiting period in health insurance signifies the time the insured must wait before filing a claim for a condition. As previously noted, health insurance companies often offer cover for internal congenital illnesses. However, until the waiting time is over, you will not be able to receive coverage. Most health insurance plans provide it after a two-year waiting period. It implies that it will need two renewals before you may submit a claim for congenital disorders. When the waiting period ends, you can quickly obtain the treatment costs.

Congenital anomalies have a 2-year waiting period that is only relevant if your child receives a diagnosis of the condition after you purchase a health insurance policy. The illness could come under a pre-existing condition if an assessment is done before buying the coverage. Then, before receiving coverage, you might need to fulfil a waiting period that lasts a maximum of four cycles. Examine the details of your health insurance plan's coverage. Carefully review your paperwork to determine the precise waiting period for congenital disorders and pre-existing conditions.

Treating Congenital Diseases

Most congenital illnesses in children may be managed with medication in the beginning stages to relieve symptoms and avoid consequences. However, its type and diagnosis will determine its course of therapy. Infants with structural congenital anomalies may need pediatric surgery to address the issue. While certain diseases, like Down syndrome, may be identified during pregnancy with a blood test, others might need more testing. Doctors may also advise pregnant women to submit to several tests to diagnose the illness. It may include amniocentesis, CVS (Chronic Villus Sampling), ultrasounds, and other tests.

To Conclude

Congenital illnesses have long-term effects. Your baby may have a range of health issues throughout their lifetime. Additionally, the costs of treating these conditions will deplete your finances. You can address congenital illnesses in the initial stages, even if they are not always preventable. It might aid in managing symptoms and prevent subsequent problems. Plus, you need to seek advice on how to keep your child from acquiring a disorder. Health insurance plans in India cover internal congenital illnesses. It is a good idea to purchase health insurance in advance to control unanticipated expenditures.


Q: How can you prevent congenital diseases?

A: Take the following steps to protect your child from developing congenital illnesses:

  • Consume nutrient-rich, vitamin- and mineral-rich meals.
  • During the 1st trimester of pregnancy, take folic acid supplements.
  • Do not take medications that might cause defects at birth.
  • Keep up an ideal weight while managing your diabetes.
  • Avoid using drugs, smoking, and drinking while pregnant.
  • Get the necessary vaccinations, notably those for rubella.
  • Avoid encountering dangerous substances like lead and insecticides.
  • Avoid going to areas where a virus or sickness is rampant.

Q: What is the difference between congenital and acquired diseases?

A: A congenital disorder may be evident from birth in an infant and may have been passed down from parents or ancestors. Acquired disease is the opposite of it. It is an illness acquired at any moment during a person's lifespan and may not even exist at birth. They are also not inheritable. Congenital diseases can be caused by genetic conditions, maternal age, infections, and other factors, whereas acquired diseases come from germs spread from one person to another.

Q: What causes congenital diseases?

A: Congenital disorders cannot be attributed to any particular cause. The potential causes are as follows:

  • Genetics: Variations in the genes impact how people grow and develop.
  • Consanguinity: Children whose parents are blood relations frequently have congenital abnormalities.
  • Environmental factors: Taking certain medications, using illegal drugs, or drinking alcohol while pregnant can result in congenital impairments in children.

Q: What is the importance of health insurance?

A: Healthcare is essential today, and everyone is entitled to high-quality, affordable medical care. Ailments are becoming more frequent, and medical care expense is rising. Therefore, it is vital to have adequate health insurance to maintain financial security even in times of disaster. Plans for health insurance achieve their goal of covering various medical costs, including hospitalization and other expenses associated with receiving medical treatment.

Q: What do you need to look for in health insurance?

A: Before purchasing medical insurance, you should consider the following factors:

  • Option of a hospital network that offers simple access to all hospitals around your home.
  • Waiting periods for pre-existing conditions and specific disorders, particularly congenital problems.
  • A sufficient cover for your child's anticipated medical expenses.
  • Perks like ambulance fees, doctor visits, physical exams, etc.
  • A higher premium for additional coverage.


This article is issued in the general public interest and meant for general information purposes only. Readers are advised not to rely on the contents of the article as conclusive in nature and should research further or consult an expert in this regard.

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