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What is a pre-existing condition?

October 24, 2010

Question: What is a pre-existing condition?

Answer: A pre-existing condition is a medical condition or disease that was present for a specified period, up to two years, before a health insurance policy was issued.

If you are eligible for group health insurance, federal law limits how an insurer can define a pre-existing condition and how long treatment for the pre-existing can be excluded from coverage. Under the federal Health Insurance Portability and Accountability Act (HIPAA), a pre-existing condition is defined as a condition for which you received medical advice, care, treatment or a diagnosis within the six months prior to enrolling in a health insurance group plan.

For those who do have a pre-existing condition, HIPAA allows a temporary health insurance exclusion for treatment. In most cases, your insurance company can exclude medical coverage of your pre-existing condition for 12 months (up to 18 months for late enrollees). During that time, the health insurance company pays benefits for other medical care and treatments, just not those related to the excluded condition.

If you have a pre-existing condition, it may be important to maintain medical insurance coverage. This is because those who have a history of health insurance coverage can reduce the pre-existing condition exclusion period by providing proof of "creditable coverage."

Individual policy rules differ

However, HIPAA does not provide the same protection to those enrolled in individual health plans. Health insurance for self-employed or other non-group policies may permanently deny medical coverage for a pre-existing condition. In addition, if you have no prior history of health insurance, a company may decline to insure you.

Private insurers argue that denying coverage to those with a pre-existing condition is necessary to keep affordable family health insurance available to others. However, the federal government is taking steps to stop the practice. The recently passed health care reform changes how insurance companies address pre-existing conditions.

Starting in 2010, children can no longer be denied medical insurance or benefits because of a pre-existing condition. In 2014, this protection will be extended to all U.S. residents. In the meantime, states are in the process of creating high-risk pools to provide temporary health insurance for those with pre-existing conditions.

Maryalene LaPonsie

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