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Defining Pre-Existing Conditions

Starting in 2014, insurers are not permitted to deny individuals health insurance coverage or charge more for coverage because of pre-existing conditions. In the meantime, confusion exists among many consumers about what qualifies as a pre-existing condition.

The University of Pittsburgh Medical Center defines a pre-existing condition as a medical condition that occurred before a program of health benefits went into effect. Some theories hold that a pre-existing condition can be either any condition for which the patient has already received medical advice or treatment prior to enrollment in a new insurance plan, or anything for which symptoms were present and a prudent person would have sought treatment.

So, is there a universal list of clearly defined pre-existing conditions? The simple answer is “no.” Conditions deemed pre-existing vary from insurer to insurer, and range from the physical to the psychological. That is one reason why it is essential to meticulously review plans offered by each insurer in your area prior to applying for coverage. Medical conditions that are considered pre-existing conditions by a large percentage of insurers include:

  • Pregnancy
  • Cancer
  • Asthma
  • HIV
  • Bipolar Disorder
  • Lupus
  • Parkinson’s Disease
  • Down Syndrome
  • Arthritis
  • Stroke

Insurers implement windows of time for coverage of pre-existing conditions – in other words, each insurer sets parameters for how far back conditions need to have occurred in order to warrant coverage. These parameters can range from six months to five years, though the longer periods are rare.

 

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