PED, waiting period and moratorium

Check a pre-existing condition against the 36-month look-back, the waiting periods and the 60-month moratorium, and draft a note for the claims committee.

The question it answers

Can this claim be contested for a condition the patient did not declare?

You give it: The policy history (inception, ported cover, sum-insured increases), the claim, and each condition with its dates.

You get: A recommendation, the dates behind it, the flags with their sources, and a draft note for the claims committee.

The idea

Two clocks decide whether a condition the patient did not declare can still be contested: a 36-month look-back and a 60-month moratorium.

Rules that run, in order

1. The 36-month look-back defines what is pre-existing
2. The waiting period for pre-existing disease
3. Specific waiting periods
4. The 60-month moratorium on non-disclosure
5. A new clock for each sum-insured increase

How well the rules are sourced

The look-back and the moratorium are read in the Master Circular (Official text). The rule that a sum-insured increase starts its own clock is Secondary and Unverified, and the page says so.

What it does not do

It never infers that a condition relates to the claim: that is the reviewing doctor’s judgment. Any repudiation needs the committee’s approval.

Steps

1. Enter the policy history. First inception date, any continuity from a ported policy, and each sum-insured tranche with its start date.
2. Enter the claim. The admission date, the amount, and whether the admission follows an accident. If fraud has been established the worksheet stops, because the moratorium does not protect fraud.
3. Describe each condition. Whether it was declared at proposal, when it was diagnosed, the last advice or treatment, and whether it relates to the claim.
4. The look-back decides what is pre-existing. A condition diagnosed or treated within the 36 months before inception counts as pre-existing, and a waiting period applies to it.
5. The moratorium decides what can still be contested. After 60 continuous months, cover cannot be contested for non-disclosure except for established fraud. Each sum-insured tranche runs its own clock; whether an increase restarts it is shown as an unverified rule.
6. Read the recommendation. The result shows the verdict, the sum insured that is protected and what is still contestable. A draft referral note for the Product Management Committee or its three-member sub-group is ready to read and download.

Every case on this site is synthetic. These are working drafts and illustrations, not a claim decision or legal advice. The interactive worksheets need JavaScript; nothing is sent anywhere.