Understanding the Terms of Your Policy: Waiting Period, Pre-Existing Conditions and Exclusions
Learn about the terms that are relevant to you as a policy holder of Prudential's health and medical coverage
Get to know important policy terms
What is a waiting period within medical and health insurance coverage?
Waiting period is a span of time in which you cannot claim some or all the policy benefits from the insurer.
The duration of the waiting period and its terms and conditions vary according to the policy and benefit type. Thus, it is essential to understand the duration and terms of the waiting period stated in your policy contract.
Do note that for any claims not offered under the Hospital Alliance Services (HAS) facility, the customer is advised to pay first and submit the claims for reimbursement with all supporting documents upon completion of treatment(s). Reimbursement claim is subjected to policy terms and condition.
What are the types of waiting period and what if the Policy Holder is diagnosed with a condition during the waiting period?
Less than 30 days from the policy/certificate’s commencement date
The medical benefit is not claimable and HAS facility is not available unless the admission is due to injuries caused by an accident. Any Pre-Authorisation Letter (PAL)/Guarantee Letter (GL) request for such accident cases during this period may require the submission of supporting documents to exclude any underlying pre-existing and chronic disease(s). E.g. knee pain or backache could be a prolonged condition and the request may be subjected to additional questions to determine the actual cause of the condition.
30 to 90 days from the policy/certificate’s commencement date
The medical benefits may be claimable after 30 days subject to review. PAL/GL facility is not available.
Up to 120 days from the policy/certificate’s commencement date
The medical benefits are claimable except for the “specified illnesses” which are outlined in your policy document under Exclusions clause.
Beyond 12 months from the policy/certificate’s commencement date
Maternity complications benefit is now payable under PRUValue Med, subject to terms and conditions of the policy. Please review the Table of Benefit here. The policyholder is required to pay and make a claim where the reimbursement will be subject to review.
More than 24 months from the policy/certificate’s commencement date
The medical benefits may be claimable for conditions/illnesses requiring surgical intervention, acute conditions, chronic illnesses and specified illnesses.
Major medical conditions are payable subject to benefits limit, policy exclusion and general exclusion. If the medical condition(s) is pre-existing or was not disclosed prior to the policy being issued, Guarantee Letters will not be issued. The policyholder is required to pay on his own and make a claim where the reimbursement will be subjected to review.
Please take note that the policy shall be indisputable after it has been in force for more than 24 months from the Commencement Date. However, the policy may be voided if we are able to show that there is misrepresentation /pre-existing/nondisclosure or that the customer has suppressed a Material Fact.
What is a pre-existing condition?
Pre-existing means a physical and/or mental condition that existed before submission of the proposal form. If the condition was not declared upon submission of the proposal form or when a policy is reinstated (due to lapsation), it will not be covered. In addition, the benefits and/or terms of the policy may be subjected to change due to the non-disclosure.
All policyholders have a duty to provide all relevant information and details required without any misrepresentation to Prudential when completing the proposal form.
Policy holders also have to disclose to Prudential any matter which may not be covered in the proposal form, that they know could be relevant to Prudential’s decision on the policy rates and term.
What are the types of exclusions within medical and health insurance coverage?
There are two types of exclusions:
1. General exclusion refers to risks that are not covered by the insurer and it applies to all customers.
The example of general exclusions are plastic/cosmetic treatment, dental condition, congenital condition and General Practitioner treatments/Specialist Outpatient Treatments that are not part of pre-hospitalisation treatments
2. Specific exclusion refers to risks that are not covered by the insurer that are specific to you based on your previous medical history.
Please ensure that you go through and understand the General exclusions or Specific exclusions (if there is) that will be clearly stated in the policy contract.