IRDAI License Number: IRDAI/INT/ISNP/2022/250
The congenital disease also known as birth defects is a medical condition which exists in a human body before birth. Such disorders in the human body are normally described by structural deformities are known as congenital anomalies meaning defect in the developing foetus.
External Congenital Anomaly is basically the congenital anomaly where the defect can be seen on the parts of the body.
Internal Congenital Anomaly, on the other hand, is where the defect is not visible on the outer parts of the body. For example – Hole in the heart etc.
The cause of congenital disabilities is due to a genetic disorder or even environmental factors. It involves infection, chromosomal abnormality etc. The result of the disorder mostly relies on the complex interaction between pre-natal deficit and post-natal circumstances.
Below are some of the examples of congenital disorders:
In most group medical insurance policies, the insurance company does not provide coverage for congenital diseases and lists it under exclusions of the policy. Although, the coverage can be attained by the policyholder, which in group insurance is an organisation by attaching an add-on to the main policy by paying extra premium. To ensure the premium amount does not increase a lot due to this add-on, policyholders can apply a deductible clause in it. This will mean that in case of a claim the policyholder will have to share some part of the claim amount with the insurance company.
Surma Enterprises who are in the business of printing had thought of giving their employees extra benefit as part of their CTC. Many companies these days are offering extra perks to attract employees and cut down on attrition rate. Surma Enterprises offered group medical insurance to its employees and included the add-on congenital diseases coverage in the group insurance policy. To keep the premiums in check, the company opted for INR 10,000 deductible limit clause in the policy. Recently one of the Company Employee Raj Verma, contacted the group medical insurance company to get reimbursement for the treatment of his daughter's congenital condition.
Verma’s daughter a 10-year-old kid has Benjamin syndrome which resulted in dental caries. The dental treatment cost INR 35,000 and the claim for the same was submitted to the insurance company for approval. As the group medical insurance policy included the congenital disease and offered coverage for the same, the claim was approved by the insurer. As this particular group insurance policy came with a deductible limit of INR 10,000 the insurance company reimbursed INR 25,000 out of the INR 35,000 claim submission to Mr. Raj Verma for his daughter’s treatment. Hence the coverage of congenital disease helped the company’s employee to take benefit of the group medical coverage and get financial benefit in reimbursement for the medical treatment.
