Health Insurance What’s the Definition of a Pre Existing Condition

When you apply for health insurance, either on your own or through your employer, you may be asked to report any “pre-existing conditions” you have. It is very important to understand how the concept of the pre-existing condition will affect your health insurance policy and any reimbursement paid out by the company.

A pre-existing condition is any illness, injury, or condition that existed prior to the effective date of the policy. This can be as simple as a missing tooth, or as complicated as a previous diagnosis of cancer or heart disease.

There are several ways that health insurance companies handle pre-existing conditions. It is vital that you examine all the contract language or benefit information for the plan before you sign up, so that you will know what to expect when the company processes your claims. A few extra minutes now could save you hours on the phone with the insurance company later! Be on the look out for any of the following terms:

– Waiting Period: This means that treatment relating to your pre-existing condition may be covered, but only after the plan has been effective for a certain amount of time. Waiting periods typically range from six months to two years, depending on the insurance company and the type of pre-existing condition (the more costly pre-existing conditions typically result in longer waiting periods).

– Exclusions: If the insurance plan states that treatment for your pre-existing condition is excluded, then your insurance will deny all treatment related to that condition, even if the treatment itself is generally covered by your plan. If you receive an explanation of benefits from your insurance denying treatment as treatment for a pre-existing condition, make sure that the treatment was really for that condition, and not for some other ailment. If you believe the treatment/visit/radiographs were to treat something other than your pre-existing condition, check with your doctor’s office, and make sure they reported the correct diagnosis on the claim.

– Higher Premiums/Denial of Coverage: Depending on the pre-existing condition, the insurance company may require higher premiums, or, in the most extreme cases, may decide not to offer you any coverage whatsoever.

Regardless of how your insurance ultimately responds to your pre-existing condition, it is important that you, as the consumer, are aware of all of the possibilities. If possible, compare several different insurance companies and plans, until you find the plan that offers the best coverage for your pre-existing condition.