In general, a pre-existing condition is defined as any sickness, injury or medical condition that existed before the start of your coverage, whether or not diagnosed by a physician, that you showed signs or symptoms of or received medical attention for.
Each insurance company will have its own requirements, typically of seven, 30, 80, 180 or 365 days, that your condition must remain “stable” or unchanged before your coverage takes effect. This is either the day you leave on your trip (for emergency medical or trip interruption) or the day your policy takes effect (for travel coverage, such as trip cancellation).
While each insurer has its own definition, essentially a medical condition or injury is considered “stable” when all of the following are true:There has been no deterioration of the medical condition.There have been no new symptoms or more frequent symptoms.There has been no change in treatment or alteration of medication.There has been no treatment received, prescribed or recommended by a physician or other registered medical practitioner.There is no pending lab results or diagnostics.There has been no hospitalization or referral to a specialist.
Travel insurance companies normally exclude pre-existing conditions from coverage, which ranks among the most frequent reasons for denial of travel insurance claims. What’s more, you don’t need an official diagnosis from a health care professional to have something designated a pre-existing condition for travel insurance purposes. If your medical record reveals you reported symptoms of a condition that was later diagnosed, that is enough to have that condition deemed ineligible for coverage.
To determine what qualifies as a pre-existing condition, a travel insurance company can review your medical records for the stipulated number of days before the day the policy was purchased. If you had any changes in your medical status during that period, such as a new diagnosis, a decline in health or the addition of new prescription medication, the condition will be considered pre-existing.
For example, say you were diagnosed with and prescribed medication for high blood pressure on January 15 and you plan to take a trip to Mexico on March 19, or 63 days later. Based on your age, your travel insurance provider requires a 30-day stability period before you leave on your trip for your condition to be covered for emergency medical insurance. As long as your symptoms and treatment of your high blood pressure do not change during that time, it should be covered by your medical insurance.
However, if, for example, you receive a change of dosage of medication, either an increase or decrease, during those 30 days, your condition is now not considered stable and will be ineligible for reimbursement without additional coverage. Keep in mind that you are still eligible for medical treatment if something else happens on your trip even with a medical exclusion. For example, if you fall down some stairs and break your wrist, those medical expenses are covered.
Tips for getting insurance when you have a pre-existing condition
By Elizabeth Cohen CNN Senior Medical Correspondent
(CNN) — Nineteen-year-old Stuart Wald is not likely to grow out of his schizophrenia, bipolar disease and attention-deficit disorder. But he will, with 100 percent certainty, grow out of the health insurance coverage he has through his father’s employer — and that day is just a few years away.
“It’s a huge problem, because insurance companies don’t want to insure sick people,” says one expert.
The Walds (not their real name) know he’ll never get insurance on his own because he has not just one but three pre-existing conditions. Without insurance, it will cost the Walds thousands of dollars a month for his treatment and care.
If Stuart could get insurance through his own employer, that would solve the problem. With “group insurance,” you can’t be denied coverage because of pre-existing conditions. But millions of people can’t get insurance through a job for a variety of reasons: They’re self-employed, or their employer doesn’t offer health insurance, or, like Stuart, they’re too sick to work.
That’s when they’re forced to find insurance on the “individual” market.
Our “Empowered Patient” inbox is filled with desperate pleas from people with pre-existing conditions searching for individual insurance. As a matter of fact, we get more e-mail on this topic than on any other.
Stuart’s father, Nathan Wald, wrote to us a few weeks ago.
“He needs lifelong medications and psychiatric therapy,” Wald wrote. “Can you give us advice on how he can get benefits?”
According to the Kaiser Family Foundation, 21 percent of people who apply for health insurance on their own get turned down, charged a higher price or offered a plan that excludes coverage for their pre-existing condition.Watch more on health insurance and preexisting conditions »
“It’s a huge problem, because insurance companies don’t want to insure sick people,” said Nancy Metcalf, senior program editor for Consumer Reports. “They’re a business. They don’t want to insure people they know are going to cost them a lot of money.”
The health insurance industry doesn’t deny that people are rejected or charged higher premiums because of pre-existing conditions.
The industry’s trade association, America’s Health Insurance Plans, has a proposal to help people with pre-existing conditions as part of a comprehensive health-care reform plan.
But there’s a catch: The association says insurance companies could guarantee coverage for people with pre-existing conditions only if all Americans are required to purchase coverage. If that happens, the group says, not only would people with pre-existing conditions be covered, their premiums would not be higher. You can read the complete proposal on the association’s Web site.
“We strongly believe that every American, including those with pre-existing medical conditions, should have access to health care coverage,” says Robert Zirkelbach, an association spokesman.
Health care reform, of course, is in the air, and in the coming months or years there might be relief for people with pre-existing conditions. This week, President Obama announced a commitment from insurance companies, doctors, hospitals and pharmaceutical companies to lower health care costs as part of an effort to fund insurance for those who don’t have it.
Finding individual insurance when you have a pre-existing condition is tough but not impossible.
“We have been successful,” said Kevin Lembo, a state health care advocate with the state of Connecticut. “There are options out there.”
1. Become a group of one.
In about a dozen states, you can be a group all by yourself for insurance purposes. What this means is that you become, in effect, just like any other company, and insurers can’t deny you insurance or charge you higher premiums because of your pre-existing condition, according to Lembo.
“You’d be surprised at the number of folks who open their own landscaping business” to get the group of one, he says.
To find out whether your state will allow you to become a group of one, see this list from the Kaiser Family Foundation (look at the column headed “Definition of Small Group,” and look for “1-50”).
For more information on becoming a group of one, see this advice from the American Diabetes Association.
In states where you can’t become a group of one, you can become a group of two.
“You can hire your brother-in-law to become a subcontractor for your landscaping company,” Lembo said. “It’s horrible, but what else are you going to do?”
An important note: Under these rules, an insurance company might be allowed to exclude coverage for your specific condition for a short period of time, usually about six months.
2. If you’ve been laid off, get COBRA.
COBRA can be extremely expensive, but it’s worth digging deep in your pockets for the premiums, because it may be difficult, if not impossible, to get insurance any other way, Consumer Reports’ Metcalf says. If you’ve been laid off since September 1, you’re eligible for a 65 percent discount on COBRA premiums. For more information, visit the Department of Labor’s Web site.
3. When you lose your employer-related insurance, apply for new insurance within 63 days.
In all states, a designated insurance company — charmingly called “the insurer of last resort” — has to take “all comers” in insurance lingo. You have to apply for this insurance within 63 days of losing your group insurance. For all the rules, read this explanation from Families USA (scroll down and look for the “HIPAA eligible” heading).
Here’s the bad news: Although in some states there are limits to what the “insurer of last resort” can charge you, in other states, there aren’t. In those states, “the sky’s the limit,” Metcalf said. “They can and will charge you a fortune. It could be, say, $1,400 a month in premiums with a $5,000 deductible. But some people pay that because it’s the only game in town.”
To find out the rules in your state, visit the Kaiser Family Foundation’s State Health Facts or contact your state insurance commissioner.
4. Find out whether your state has a high-risk pool.
State high-risk pools are specifically for people with pre-existing conditions who can’t find affordable insurance on their own. Thirty states have high-risk pools, insuring 175,000 people, according to the American Diabetes Association, which lists the states on its Web site.
5. See whether your professional organization offers group insurance.
Some professional groups, such as those representing real estate agents and freelance writers, offer health insurance. Check and see whether your profession does the same.
Here’s another piece of advice, offered somewhat tongue in cheek: Move to Maryland, Massachusetts, New Jersey, New York or Vermont.
“In those states, everyone has to sell to you,” said Cheryl Fish-Parcham, deputy director of health policy at Families USA. Not only do insurance companies have to sell you a policy in those states, there are limits on how much they can charge you, she says.
For more help in finding insurance when you have a pre-existing condition, you can contact the Cover Me Foundation at 877-678-7631 or Coverage For All at 800-234-1317.
As for Stuart Wald, his parents are helping him apply for disability. To find out about public assistance programs in your state, see this guide from Families USA.
It’s been slow going, but they hope they’ll be successful.
“It’s kind of like peeling an onion,” said Stuart’s stepmother, Connie Wald. “Each time you think you are getting somewhere, there’s a roadblock. It is very emotionally draining.”
CNN’s Jennifer Pifer Bixler and Sabriya Rice contributed to this report.
All About Health Care Issues
Pre-existing Condition Exclusion Period: Definition and Limits
What Is the Pre-existing Condition Exclusion Period?
The pre-existing condition exclusion period is a health insurance provision that limits or excludes benefits for a period of time. The determination is based on the policyholder having a medical condition prior to enrolling in a health plan. The Affordable Care Act (ACA) drastically curtailed pre-existing exclusion periods, but they can still occur.Key TakeawaysIn the past, if individuals could prove that they had creditable coverage before joining the new plan, the exclusion period could be waived.Some insurance carriers still have pre-existing condition exclusion periods but not many, thanks to the passage of the ACA.Insurers in some states could have restrictions added on whether they can include a pre-existing condition exclusion period.Today, insurers cannot deny coverage to somebody based on pre-existing conditions, nor charge more.A pre-existing condition is any health problem or ailment that was previously diagnosed at the time of applying for coverage.
How the Pre-existing Condition Exclusion Period Works
A pre-existing condition exclusion period limits the number of benefits that an insurer has to provide for specific medical conditions and does not apply to medical benefits afforded by a health insurance policy for other types of care.
For example, a policyholder may be excluded from receiving benefits for a pre-existing heart condition for a period of months after starting a policy, but may still receive care for conditions that don’t qualify as pre-existing, such as the flu.
All Health Insurance Marketplace plans must cover treatment for pre-existing medical conditions. Medicare also typically covers pre-existing conditions without lengthy waitlists.Conditions for Exclusion
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires insurers to provide coverage to individuals in group health plans and places restrictions on how insurers can restrict some benefits.
Prior to HIPAA, workers with chronic health problems or ongoing treatments and medication often felt forced to stay in their current job because a new employer’s health plan could impose a long wait for coverage or refuse to cover any cost for the condition at all. The act set guidelines on how and when insurers could exclude health coverage from individuals who had pre-existing conditions before joining the policy.
HIPAA did allow insurers to refuse to cover pre-existing medical conditions for up to the first 12 months after enrollment, or 18 months in the case of late enrollment.
Pre-existing condition exclusion periods are regulated policy features, meaning that the insurer is likely to have an upper limit on the period of time for which the exclusion period will last.Reducing the Pre-existing Condition Exclusion Period
Individuals can reduce the pre-existing condition exclusion period by proving that they had creditable coverage before joining the new plan, usually with a certificate of continuous coverage from the previous insurer, which may also be able to offer other forms of proof.
Insurers have to provide a written notice indicating that a pre-existing condition is applied, and the exclusion period countdown begins immediately after any plan-required waiting period. In some states, insurers may place additional restrictions on whether they can include a pre-existing condition exclusion period.The ACA and Pre-existing Health Conditions
Under the Affordable Care Act, passed in 2010, it is illegal for insurance companies to deny coverage to or charge more for people with pre-existing conditions of any kind. Health insurers can no longer charge more or deny coverage to you or your child because of a pre-existing health condition like asthma, diabetes, or cancer. They cannot limit benefits for that condition either. Once you have insurance, they can’t refuse to cover treatment for your pre-existing condition.
The Affordable Care Act has blocked many insurers from being able to impose the pre-existing condition exclusion period, but it does still occur. This happens usually because the periods have legacy acceptance built in from previous policies; this sort of policy, purchased before March 23, 2010, is called a “grandfathered health plan.”What Is a Pre-existing Condition?
A pre-existing condition is any health problem, like diabetes, or cancer, that you had before the date you applied for insurance. Insurers cannot refuse to cover treatment for your pre-existing condition or charge you more under the ACA.For How Long Can a Pre-existing Condition Be Excluded?
The Affordable Care Act made it difficult to exclude pre-existing conditions from coverage. As a result, employer-sponsored group health plans almost never have them, although a new employee may have to wait up to three months for coverage overall. As soon as the plan becomes effective, they are fully covered, with no exceptions for pre-existing conditions.
The same goes for individual insurance purchased through a state or the federal health marketplace. Should a non-ACA-compliant plan still exclude pre-existing conditions, in most cases, it can only do so for a certain period—12 or 18 months, depending on when you enrolled.Can I Get Coverage If I have a Pre-existing Condition?
Yes. Under the Affordable Care Act, health insurance companies can’t refuse to cover you or charge you more just because you have a pre-existing condition— that is, a health problem you had before the date that new health coverage starts. The only exception to the pre-existing coverage rule is for certain “grandfathered” individual health insurance plans—the kind you buy yourself, not offered through an employer. They don’t have to cover pre-existing conditions.Do Short-Term Health Plans Cover Pre-existing Conditions?
No, short-term health plans usually don’t cover pre-existing conditions, and claims will be denied if the service or treatment results from one. The length of time that short-term policies “look back” for pre-existing conditions varies by state, ranging from the previous six months to five years.Can Pregnancy Be Considered a Pre-existing Condition?
No, pregnancy cannot be considered a pre-existing condition, thanks to the Affordable Care Act. (Previous to the act’s passage in 2010, it could be.) Also, newborns and newly adopted children who are enrolled in a plan within 30 days cannot be subject to pre-existing condition exclusions.