What is a Pre-Existing Condition?

A pre-existing condition is a condition that exists prior to the application for a health insurance plan, or alternately it can refer to any condition that presently exists, and may be thought of in a solely medical context. Usually, the term pre-existing condition is thought of as applying to health insurance because there are ways in which an insurer may either refuse to cover someone if they have a current medical condition, or they may place a period of limitation on someone’s coverage. Rules about when an insurance company can deny coverage based on a pre-existing condition are determined at the federal and sometimes, state level.

Especially when people are applying for health insurance privately, they may note the insurance company’s ability to exclude any coverage that would be used to treat a pre-existing condition. This can make finding private health insurance extremely difficult if a person has a chronic condition or a recent health problem that still requires treatment. It’s important to remember that insurance companies do not want to spend money and function primarily to limit costs. People in the peak of health are the most eligible for private insurance plans because they hazard the lowest risk of needing health care. Health insurance companies can either sell very high-priced policies to people with poor health, that won’t cover pre-existing conditions, or they can refuse to insure them.

Private insurance companies may also instead offer an affiliation period, where any care for a pre-existing condition wouldn’t be offered for several months. Companies usually aren’t allowed to both exclude treatment of these conditions and then impose an affiliation period too. It’s typically one or the other, but people looking to buy insurance should make certain that the affiliation period is not exceptionally long. When that is the case, they’re still not getting the health coverage they may need.

Differences exist when health insurance is part of the benefit of working. When people belong to a company that offers health coverage, it may be much more difficult for an employer’s insurance company to impose affiliation periods or pre-existing condition limitations. They can do either one sometimes, but they are usually limited to excluding coverage of the condition to one year. Moreover, insurance companies aren’t able to do that much of the time. If the new enrollee had insurance that was uninterrupted prior to enrollment in the new health plan, US law, specifically the Health Insurance Portability and Accountability Act (HIPAA), makes it illegal for the new insurer to limit coverage on the basis of pre-existing condition. This only applies to group insurance, however, and does not govern the way a private insurer may act.

The other way in which the term, pre-existing condition, may be used is when doctors need to treat patients for an emerging condition. They need to take medical histories to determine if any other condition “pre-exists” that might change the way to treat a new health problem. Treatment for any illness often has contraindications, or an indication not to use the treatment if other conditions are present. In this sense, doctors must know about pre-existing conditions so that they don’t prescribe the wrong treatment that might be contraindicated.