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Does health insurance cover Congenital Diseases in India?

Team AckoJan 17, 2024

Usually, disease and bodily weaknesses can be avoided by following a healthy diet, sleeping adequately and exercising regularly. However, individuals born with Congenital Diseases seem to develop these disorders despite following healthy habits. Treatment costs for these conditions could amount to a lot. Usually, health insurance helps us to cope with the financial aspects of medical uncertainties. So, one may wonder if health insurance covers Congenital Diseases in India. Read ahead to find out!




What are Congenital Diseases?

A congenital disease or disorder is a medical condition that one may be born with. These can either be inherited or triggered by environmental stimulants. A joint report by the World Health Organisation (WHO) and March of Dimes (MOD) in 2016 states that over 1.7 million people residing in India suffer from Congenital Diseases. This roughly translates to 6 to 7% of the Indian population.

The origin of these disorders is usually during pregnancy. And they can be detected before, at or after childbirth. The medical implications of these disorders are not always severe. Nonetheless, in certain cases, they can have serious implications. Usually, internal congenital disorders are not easily noticeable. However, external congenital disorders may be easier to identify.

Does a health insurance policy cover congenital diseases?

If you are planning for pregnancy, it is natural to be concerned if your child may incur a Congenital Disease. Especially if your family has a history of suffering from a particular disorder. In some cases, it is possible to test for congenital conditions before birth. Also, there may be treatments you can avail of to reduce the possibility of your child being born with a Congenital Disease.

Fortunately, based on the guidelines put forth by IRDAI (Insurance Regulatory and Development Authority of India) in 2019, insurers usually cover congenital diseases. Coverage may include expenses arising from diagnostic tests, hospitalisation, treatment, etc. However, the extent of coverage may be dependent on the type of plan you buy and its sum insured value.

Unfortunately, a health insurance policy may not cover all types of congenital conditions. As per regulation put forth by IRDAI, coverage is usually offered only for individuals suffering from internal congenital disorders. Thus, in the case of external conditions, the insurer will not be held liable for covering the medical expenses resulting from the treatment.

Types of Congenital Diseases

Some of the common congenital disorders that occur in India may include the following.

  • Heart disease

  • Deafness

  • Spinal muscular atrophy

  • Down syndrome

  • Cystic fibrosis

  • Hypothyroidism

  • Cerebral palsy

  • Neural tube defects

Treatment of Congenital Diseases

The treatment for Congenital Diseases may vary depending on the type of disease. Most congenital conditions can be treated during the early stages. Such treatment may help cope with symptoms and prevent further complications. To facilitate this, a doctor may prescribe various tests to a pregnant mother to diagnose the disorder as early as possible.

Thus, the costs of diagnostic tests and treatments may add up. Moreover, children diagnosed with these conditions may require paediatric surgery to treat the disorder. So, as might be expected, the costs of long-term medications and surgery can be expensive. Needless to say, amniocentesis, ultrasound scans, blood tests and other tests may also heap up expenses.

Also, read: Critical Illness Insurance

Waiting period for Congenital Diseases under health insurance

As mentioned earlier, health insurers usually offer coverage for Congenital Diseases. However, you may not be able to raise a claim for a Congenital Disease during the waiting period. In health insurance, the waiting period refers to the duration the insured has to wait to make a claim for a particular ailment.

Most health insurance plans have a two-year waiting period for availing coverages for congenital conditions. Meaning, that a claim cannot be raised for a congenital condition until two policy cycles are completed. However, this holds true only if the diagnosis is made after buying the health insurance policy.

Alternatively, if the diagnosis was made before buying the policy, the disease may be considered a pre-existing condition. In that case, you may have to complete a waiting period of up to four policy cycles before availing coverage. Go through the policy wordings of your health insurance plan to find out more about the waiting period clause.

List of tips to prevent Congenital Diseases

If you are a pregnant mother, you may be worried about the health of your baby. Well, fret not! Here are some tips you can follow to reduce the risk of your child being born with a congenital disorder.

  • Consume vitamin-rich fruits and vegetables

  • Try to achieve and maintain a healthy Body Mass Index (BMI)

  • As per the advice of your doctor, consume folic acid supplements

  • If you suffer from diabetes, try to keep it under control

  • As per the advice of your doctor, avoid medications that may trigger disorders

  • Avoid consuming harmful substances like cigarettes, alcohol and drugs

  • Avoid contact with harmful chemicals such as lead and pesticides

  • Avoid visiting places where there may be a high risk of catching an infection

Disclaimer: The above-mentioned tips are for information only. Kindly consult your doctor to get authorised medical advice.

Advantages of opting for ACKO Health Insurance Policy

In 2022 ACKO launched a new health insurance plan called “ACKO Health Insurance Policy”. Below are some of the key advantages of opting for the same.

  • ACKO Health Insurance Policy offers a sum insured of Rs. 1 crore. Thus, in most cases, all your medical expenses will be covered under this sum.

  • Usually, there is an initial waiting period of around 90 days for policy activation. However, under this policy, you can raise claims as soon as you buy it.

  • Usually, pre-existing conditions are covered only after a waiting period of 2 to 4 years. However, under this policy, there is no such waiting period.

Disclaimer: Coverage for pre-existing conditions is only applicable if the conditions are reported while buying the policy.

Difference between Congenital and Acquired diseases

The opposite of a Congenital Disease is an Acquired Disease. Meaning, it is a disease that one may acquire after birth. Below is a table to help you understand the difference between both.

Congenital Diseases Acquired Diseases
A congenital disease may be present in a child from birth. As the name suggests, an Acquired Disease may be acquired anytime during the lifetime of a person. And may not be present at birth.
These diseases can occur due to genetic disorders, infections, maternal age, and other causes. These diseases can occur due to infectious bacteria, viruses and other microorganisms transferred from person to person.
Could be inherited from parents or ancestors. These diseases are non-inheritable.

In a nutshell

Although congenital diseases may not always be avoidable, they can be treated in the early stages. This may help to manage symptoms and avoid further complications. However, the cost of diagnostic tests and treatments may amount to a lot. Hence, it may be wise to buy health insurance in advance to manage the probable costs.

Frequently asked questions

Below are some of the common questions raised regarding Congenital Diseases and health insurance coverage for the same.

Are all congenital diseases covered under health insurance?


Usually, not all congenital diseases are covered under health insurance. As per IRDAI regulations, health insurance may cover internal congenital conditions. However, external conditions may not be covered. These external conditions may include cleft lip or palate, clubfoot, Lumbar spina bifida and others.

What is ACKO’s waiting period for pre-existing Congenital Diseases?


ACKO Health Insurance Policy offers a zero waiting period for pre-existing diseases and conditions, provided that a pre-existing condition is disclosed. That means you can avail of medical coverage for the treatment of these conditions from day one. Nonetheless, these pre-existing conditions have to be reported while buying the policy.

Note: ACKO will not be liable for covering the treatment costs of medical conditions not disclosed during the policy purchase.

To what extent will ACKO Health Insurance Policy offer coverage for pre-existing Congenital Diseases?


As mentioned earlier, the financial value of coverage offered by health insurance is proportional to its sum insured value. Fortunately, ACKO Health Insurance Policy has a sum insured of Rs. 1 crore. This may provide adequate coverage for all the treatments one may need for coping with congenital conditions.

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Disclaimer: The content on this page is generic and shared only for informational and explanatory purposes. It is based on industry experience and several secondary sources on the internet; and is subject to changes. Please go through the applicable policy wordings for updated ACKO-centric content and before making any insurance-related decisions.

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