What is considered a preexisting condition?

A pre-existing condition is a medical condition that existed before you obtained health insurance. It is significant because the insurer may not cover the pre-existing condition for the duration of the pre-existing condition period. The policy will provide for a stated time period within which it will not provide benefits for the condition.

The pre-existing condition exclusion period varies by insurance company, and also by the State in which the policy is issued. Currently, State law regulates the terms and conditions of insurance policies. For example, some States have disallowed certain types of provisions, including mcertain medical conditions to which they might otherwise apply.

All of that may change if there occurs greater Federal involvement in the regulation of health insurance, but the odds are that new laws will apply only upon the expiration of existing insurance contracts and for the issuance of new contracts after such laws are implemented.

The rationale for pre-existing condition exclusions is that medical insurance works the same way other insurances do: that insurance covers fortuitous occurrences, nor ones that are planned, intentional, or predictable. Stated otherwise, you need to have coverage in place before something adverse happens. An analogy is that just like you can't buy auto insurance after an accident to cover the cost of the accident, medical insurance only covers issues that arise unexpectedly after coverage has begun.

Pre-existing conditions are usually chronic and often costly conditions such as:

  • diabetes
  • heart problems
  • mental illness
  • asthma
  • COPD
  • Hemophilia
  • Epilepsy
  • Chronic Infections
  • a pregnancy prior to coverage
  • an injury which occurred prior to coverage.
  • multiple sclerosis, etc.
  • certain allergies
  • certain skin conditions

If you think you may have a condition that might be pre-existing you can ask the insurance company if there are exceptions and if your physician can confirm you have not suffered or been treated for the problem during the time period designated by the insurance company. Some companies may decide they cannot cover you if you are seeking individual coverage (rather than group coverage).