Congenital diseases are present at birth, but not all of them are evident right away. Some can be diagnosed later in life. Conditions like congenital heart disease, Down syndrome, and spina bifida are some of the most well-known examples.

Is Coverage for Congenital Diseases Always Guaranteed?

Whether or not insurance covers congenital diseases is not a straightforward answer. Policies and plans differ between countries and insurance companies. Some don’t cover them at all, whereas others do, but come with exclusions and limitations.

Why Exclude Coverage?

Many congenital diseases are chronic illnesses that require lifelong treatment. Insurance companies’ decision to exclude coverage for these diseases is because of the substantial financial burden it poses for them.

Many congenital diseases is exceedingly costly to treat. Hence, many insurance plans include exclusions and limitations when it comes to congenital diseases.

What are the Exclusions and Limitations?

The common exclusion is a ‘pre-existing condition.’ If your child is born with a congenital disease, they’re considered to have one of these.

Consequently, when purchasing health insurance, the insurer may decline coverage for their medical costs or treatments related to their pre-existing condition.

However, the Affordable Care Act (ACA) passed in the United States in 2010 prohibits health insurance companies from refusing coverage to children due to pre-existing conditions.

But whether or not this law is continued depends on the country’s government and the healthcare system and policies.

When Do Congenital Diseases Become Eligible for Coverage?

Some congenital conditions become eligible for insurance coverage after a specific period. For instance, some insurance companies may provide a child with coverage after two years of being diagnosed with autism spectrum disorder (ASD).

In other instances, insurance plans may include a certain threshold the child should have reached before coverage begins.

How to Secure Coverage for Congenital Diseases?

The best way to secure coverage for a congenital disease is to shop around for insurance companies and insurance plans with knowledgeable agents to determine the best plan for you and your child’s needs.

Before signing up for an insurance plan, carefully review the policy details to locate any restrictions or coverage changes.

What Happens if No Coverage can be Found?

If an insurance plan still could not be found, there are still other alternatives.

Family health programs, Medicaid, and the State Children’s Health Insurance Program (SCHIP) are government-funded programs that assist families who have kids with pre-existing conditions. Each state has a different eligibility criteria, application process, and benefit options available.

What are the Benefits of Childhood Health Programs?

Childhood health programs provide comprehensive medical care, rehabilitation services, diagnostics, and most importantly, financial assistance.

Similarly, the Children’s Health Insurance Program (CHIP) or Medicaid program offers the essential benefits of coverage for treatment of pre-existing conditions like prescription drugs, mental health care, and regular checkups. Additionally, coverage from these programs is not impacted by your child’s state of their pre-existing condition.

What is the Bottom Line?

Although Insurance companies could exclude coverage for congenital diseases, policies differ between countries and companies.

The Affordable Care Act in the United States provides coverage to children with pre-existing conditions, but this depends on the healthcare system and policies of a particular country. Therefore, it is best to shop around for insurance plans that provide the best coverage for your child’s needs.

If one cannot be found, there are still government-funded programs available to ensure that your child with congenital diseases gets the healthcare they require.