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Are Congenital Diseases Covered Under Health Insurance?

Published On Apr 04, 2023 10:00 AM By InsuranceDekho

We often hear that eating healthy and exercising regularly promote a healthy lifestyle. However, despite following healthy habits, some individuals may not be able to overcome disease and bodily weaknesses. The reason behind this is “congenital diseases."  Some individuals are born with this genetic disorder and require proper treatment. The cost of treatment for congenital diseases may hamper your finances. Therefore, a health insurance policy is a tool that can help you financially in the event of a congenital treatment or any other medical emergency. In this article, you’ll learn all about congenital disease and if it is covered under health insurance

Are Congenital Diseases Covered Under Health Insurance?

Meaning of Congenital Disease

The diseases that develop in a baby during intrauterine life and are present in them from birth are known as congenital diseases. These diseases are also called congenital anomalies or genetic disorders. Usually, these diseases can be detected in pre-birth, at birth, or during the infant stage of the child. 

The common reason for these genetic disorders among children is genetic mutations, environmental factors, maternal age, maternal health and nutrition, infections, and others. According to a collective report issued by WHO and MOD in 2016, 6-7% population in India, that is 1.7 million people are suffering from congenital diseases. Usually, a baby suffering from a congenital disease may suffer from health problems and disabilities throughout his life. Internal congenital diseases cannot be detected; however, external congenital disorders can be easily identified and treated. 

Treatment of Congenital Diseases

As there are numerous types of congenital diseases, the treatment may vary depending on their type and diagnosis. Children with functional congenital diseases can be treated through medication at an early stage. However, children suffering from a structural genetic disorder may have to undergo pediatric surgery. As a result, long-term treatment and pediatric surgery can be a financial burden.

In addition to this, doctors may suggest certain blood tests and medical examination procedures, such as chronic villus sampling (CVS), ultrasound scans, amniocentesis, and others, to pregnant mothers. Therefore, these expensive medical procedures and examinations can burn a hole in your pocket. 

Does Health Insurance Cover Congenital Diseases in India? 

According to guidelines issued by the Insurance Regulatory and Development Authority of India in 2019, all regular health insurance plans must offer coverage for congenital diseases. The insurance companies cover medical expenses related to diagnosis and treatment, including the cost of in-patient hospitalization, daycare procedures, and more. The insured amount can range from Rs. 50,000 to Rs. 6 crores. 

However, you must read your policy document carefully at the time of purchase. This is because health insurance plans in India do not cover all congenital diseases. According to the guidelines of the IRDAI, regular health insurance plans can only cover internal congenital diseases. Henceforth, the insurance company will not provide any coverage to individuals with external congenital diseases. 

Waiting Period Under Health Insurance For Congenital Diseases

Although internal congenital illnesses are covered by health insurance policies in India, you cannot access coverage until the waiting period has been completed. After a two-year waiting period, congenital disorders are typically covered by health insurance policies. Therefore, a policyholder cannot claim a health insurance policy until two years after its purchase. You can easily claim treatment expenses for internal congenital diseases once the waiting period is over. 

However, the 2-year waiting period for congenital anomalies only applies if your child is found to have the condition after you've purchased the health insurance. If your child was identified as having an internal congenital problem prior to the time you bought the policy, it will be regarded as a pre-existing condition. In this situation, you would have to wait until up to four renewals have passed before you may file a claim under your policy for congenital disorders. This is due to a 2–4 year waiting period before all pre-existing conditions are covered by health insurance companies.

Ways To Prevent Congenital Diseases 

Listed below are some ways to prevent congenital diseases in children. 

  • Consume healthy foods that are vitamin and mineral dense.
  • Keep your body at a healthy weight.
  • Avoid consuming alcohol, drugs, and cigarettes during pregnancy.
  • Do not take medications that can cause birth abnormalities.
  • Avoid coming into contact with dangerous substances like lead and insecticides.
  • Get the necessary vaccinations, including those for rubella
  • Travellers should stay away from areas where an infection, such as the Zika virus, is prevalent.
  • Take care of your diabetes (if applicable)


In conclusion, congenital diseases happen to individuals at the time of birth and stay with them their entire lives. In addition to suffering from numerous health problems, you may burn through a lot of your savings. However, a health insurance policy can safeguard you against internal congenital diseases. As a mother, you can above-mentioned preventive measures to safeguard your children.

Also read: What Happens to Health Insurance After the Death of the Policyholder?


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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