Named Ailments

What are named ailments?

Named ailments are specific medical conditions or surgeries that insurers cover only after a fixed waiting period.
They are not emergencies but high-frequency, planned medical procedures that many people undergo over time.

Common named ailments usually listed by insurers

Every insurer has its own list, but most include these:

• Surgical   treatments   for   Benign   ear,   nose   and   throat   (ENT)   disorders   and surgeries   (including   but   not   limited   to   Adenoidectomy,   Mastoidectomy, Tonsillectomy   and   Tympanoplasty),   Nasal   Septum   Deviation,   Sinusitis   and related disorders
• Cataract
• Fissure  /  Fistula   in   anus,   Hemorrhoids   /  Piles,   Pilonidal   Sinus,  Gastric   and Duodenal Ulcers
• Benign Prostatic Hypertrophy
• Surgery of Genito-urinary system unless necessitated by malignancy
• Dilatation and Curettage
• Arthritis   (if   non-infective),  Osteoarthritis   and Osteoporosis, Gout, Rheumatism, Spinal Disorders(unless caused by accident), Joint   Replacement   Surgery (unless   caused   by   accident),   Arthroscopic   Knee Surgeries/ACL Reconstruction/ Meniscal and Ligament Repair
• All types of Hernia & Hydrocele
• Hysterectomy   for   menorrhagia   or   Fibromyoma   or   prolapse   of   uterus   unless necessitated by malignancy
• Internal tumours, skin tumours, cysts, nodules, polyps including breast lumps (each of any kind) unless malignant
• Kidney Stone / Ureteric Stone / Lithotripsy / Gall Bladder Stone
• Myomectomy for fibroids
• Varicose veins and varicose ulcers
• Parkinson's or Alzheimer's disease or Dementia

Please note that every insurer has their own specific list, criteria, and waiting periods so it’s important to check the policy document for exact details.

Waiting period for named ailments

While it varies by insurer, the most common waiting periods is 2 year (standard across most retail policies)

In group health insurance (GMC)

Corporate health insurance policies offer flexibility. Employers can:

• Remove the waiting period entirely
• Reduce it to 1 year

How named ailments impact claims

If you undergo a named ailment surgery before the waiting period is over

Your claim can be:

• Rejected, or
• Only partially paid

Example:

You undergo cataract surgery 8 months after buying your policy.
If the waiting period is 24 months – the claim will be rejected.

To avoid claim issues

• Check your policy’s named ailment list before planned surgery
• Confirm with your TPA/hospital prior to admission

Tips for employees

To ensure smooth claims:

1. Read your policy wording, especially the “named ailments” section.
2. Before a planned surgery, ask HR if any waiting period applies.
3. If surgery is urgent, check if your corporate policy has a waiver

Tips for HR teams

To design a better group health insurance plan:

• Evaluate the age and needs of your workforce
• Remove named ailment waiting periods if affordable
• Communicate coverage clearly to employees
• Partner with employee benefits partner who handle claims transparently

A well-designed plan reduces claim issues and improves employee trust.