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Define Pre-Existing in Health Insurance

Applying for health insurance requires submission of multiple pieces of information from the consumer, as well as full disclosure of any and all relevant medical data. Waiting periods, limitations and exclusions commonly apply to new policies regarding pre-existing conditions. These limitations serve to protect the insurance carrier, and can be both confusing and costly for consumers.

  1. What is a Pre-Existing Condition?

    • The majority of health insurance companies share the same definition of “pre-existing condition” as it applies to coverage limitations for new policyholders. A pre-existing condition is any issue, disorder, malady or ailment for which the consumer has been counseled or treated. Each carrier has its own exclusions regarding pre-existing conditions, and they may differ from one policy to the next.

    Look-Back Period

    • The carrier’s look-back period determines limitations on benefits due to pre-existing conditions. Claims related to any pre-existing issue that occurred within a specified period of time prior to the effective date of a new health insurance policy will be declined. Common look-back periods range from one to two years, depending on the insurance company and the policy type.

    Carry-Forward Period

    • Once the pre-existing condition look-back period is established, carriers set a carry-forward date. The carry-forward date represents the day through which claims related to prior conditions will be denied. After the carry-forward date has been passed, all claims, even those related to pre-existing issues, will be processed and paid as per the provisions of the health insurance policy.

    Justification

    • While pre-existing condition limitations and exclusions may be inconvenient and problematic, it’s important to understand the carrier’s justification in restricting claims for such issues. Health insurance companies already spend billions of dollars on treatment for insured customers, yet prices and premiums continue to rise each year. Denying claims for pre-existing conditions protects the carriers from paying exorbitant medical bills for unscrupulous customers whose only intention is to buy a policy to pay for an expensive issue, then cancel coverage after treatment has been rendered.

    Pregnancy

    • Pregnancy is one of the most common differences regarding pre-existing conditions from one health insurance company to the next, as well as from one state to another. In some states, pregnancy is prohibited from categorization as a pre-existing condition, and claims must be paid without delay. Other states acknowledge pregnancy as a legitimate pre-existing issue and permit carriers to exclude claims related to both prenatal treatment and the birthing process itself.

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