Benefits and Claim Procedures: Pre-Existing Condition Limitation on Your Health Insurance Policy

This section of the policy, entitled “Limitations, Exclusions and Non-Waiver,” attempts to explain limitations of coverage, exclusions from coverage and other details of the policy so that if you have any questions, you can just turn to this section and find the answer. The first part of this section of the policy deals with “Limitations and Waiting Periods”. It is followed by the policy’s definitions of some of the terms used in the policy language. See further clarifications below the definitions.

A “Pre-Existing Condition” is a condition, whether physical or mental, and regardless of the cause:

1. for which medical advice, diagnosis, care or treatment was recommended or received during the twelve (12) month period immediately preceding the effective date of coverage under this Policy for the Insured incurring the expense; or
2. which Manifested itself during the twelve (12) month period immediately preceding the effective date of coverage under the Policy for the Insured incurring the expense.

“Manifested” means either the presentation of symptoms or the presence of a medical condition, whether physical or mental, and regardless of the cause, which would have caused a reasonably prudent person to seek medical advice, diagnosis, care or treatment, and which condition would have been medically diagnosable after the receipt of the results of medical diagnostic and laboratory tests that would have been reasonably indicated and ordered by a reasonably prudent Provider under the same or similar conditions.

Now in English: Basically this section of the policy excludes coverage for a pre-existing condition, which was not disclosed on your insurance application if certain circumstances are present. Suppose you have asthma and you didn’t disclose it on your application. Your asthma will be considered a pre-existing condition if you were diagnosed with it, or sought or got treatment for it within the year prior to the effective date of your policy. In addition, if you had it but didn’t seek out medical advice, would a “reasonably prudent person” have gotten medical advice with the same symptoms? If so, treatment for your asthma won’t be covered under the policy unless it is a covered expense (as defined by the policy) and the expense for your asthma treatment was incurred over a year after the policy was issued to you, as long as it is not excluded elsewhere in the policy.

Notice the significance of the element of judgment in determining whether a condition has sufficiently manifested itself when there was no medical advice, diagnosis, care or treatment. Needless to say, this issue has been the subject of much litigation over the years. Determining when a condition first manifested itself can be difficult and is often a question of fact for a judge or jury to decide.

If a condition is quietly present prior to the effective date of coverage, benefits are usually payable for treatment after the effective date of coverage. For example, if at the time of application you have a brain tumor that is undiagnosed and without symptoms (in other words, you have no reason to think anything is wrong), you are likely to have coverage when the tumor is discovered after the effective date of coverage. If, on the other hand, within twelve months prior to the date of application you experienced pain, blurred vision or other symptoms that would cause an ordinarily prudent person to see a doctor but you did not, there is a reasonably good chance that the insurance company would be successful in denying coverage for treatment of your brain tumor under the pre-existing condition exclusion because the condition first manifested itself in the twelve months immediately preceding the effective date of your coverage.

Note that this is not an indefinite right on the part of the company. If the medical expenses are incurred more than twelve months after the policy issue date, they cannot be excluded from coverage as pre-existing.

In this policy, the pre-existing condition limitation does not apply to childhood wellness preventive care.

*Wording may vary from contract to contract and from state to state.

Case Studies: Pre-Existing Condition Limitation on Your Health Insurance Policy

Case Study 1: Undisclosed Diabetes Diagnosis

Emily applied for health insurance without disclosing her diabetes diagnosis. She had been managing her condition independently and didn’t consider it significant at the time of application. However, after the policy was issued, Emily experienced complications related to her diabetes and required medical treatment.

Since her diabetes was considered a pre-existing condition, the insurance company denied coverage for her treatment, leaving Emily with significant out-of-pocket expenses.

Case Study 2: Unreported High Blood Pressure

In this hypothetical scenario, Michael failed to disclose his high blood pressure when applying for health insurance. He believed it was a minor health issue and didn’t consider it necessary to mention. However, within the first year of coverage, Michael suffered a heart attack due to complications related to his uncontrolled high blood pressure.

The insurance company denied coverage for his heart attack treatment, citing the pre-existing condition exclusion. Michael faced substantial financial burden as a result.

Case Study 3: Childhood Asthma

Lisa, a parent, applied for health insurance for her daughter, Lily, who had been diagnosed with asthma. Fortunately, the insurance policy included an exception for childhood asthma under the pre-existing condition limitation. Lily received coverage for asthma-related treatments, medications, and preventive care, ensuring she could manage her condition effectively.