How Do Insurance Companies Know About Pre-Existing Conditions? (2024)

FAQs

How do insurance companies know if you have a preexisting condition? ›

If you claim that you suffered injuries in a crash resulting of someone else's negligence, the insurance company may dig into your medical history. Your medical records will show what injuries or conditions you have endured in the past and compare them with your current claim.

A pre-existing condition could be known to the person – for example, if she knows she is pregnant already. People might also apply for coverage when they unknowingly have an undiagnosed condition – for example, tumor cells might be growing within but won't be diagnosed until months or years later.

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.

This means that individuals cannot be denied insurance coverage due to pre-existing conditions. Under the Affordable Care Act (ACA), guaranteed issue is a fundamental provision that ensures individuals with existing health issues have the same access to insurance as those without such conditions.

A health problem, like asthma, diabetes, or cancer, you had before the date that new health coverage starts. Insurance companies can't refuse to cover treatment for your pre-existing condition or charge you more.

A pre-existing medical condition (PEMC) is an illness or injury you had before your policy began or was renewed. Examples of pre-existing medical conditions include, diabetes, asthma, high cholesterol or a long-term back condition.

If your health plan is fully compliant with the ACA and obtained in either the individual/family market or the employer-sponsored market, you no longer need to worry about pre-existing condition exclusion periods.

A pre-existing condition exclusion can not be longer than 12 months from your enrollment date (18 months for a late enrollee). A pre-existing condition exclusion that is applied to you must be reduced by the prior creditable coverage you have that was not interrupted by a significant break in coverage.

Failure to disclose pre-existing conditions not only jeopardizes the chances of successful claims but may also lead to the cancellation of the policy in extreme cases.

Health insurance companies cannot refuse coverage 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.

When did preexisting conditions end? ›

Before 2014, some insurance policies would not cover expenses due to pre-existing conditions. These exclusions by the insurance industry were meant to cope with adverse selection by potential customers. Such exclusions have been prohibited since January 1, 2014, by the Patient Protection and Affordable Care Act.

In the health insurance world, a pre-existing condition is any injury, sickness or condition that exists before the date an insurance policy takes effect. Examples include asthma, diabetes, anxiety, depression, high blood pressure, high cholesterol and so on.

The ACA bars use of pre-existing conditions

The ACA complements the Genetic Information Nondiscrimination Act (GINA) which prohibits discrimination by most health insurance plans and employers based on genetic information such as an inherited genetic mutation associated with an increased risk of cancer.

According to Healthcare.gov, pregnancy is not considered a pre-existing condition. So if you were pregnant at the time that you applied for new health coverage: You can't be denied coverage due to your pregnancy. You can't be charged a higher premium because of your pregnancy.

Pre-existing conditions are the medical issues themselves, while the acute onset of pre-existing conditions is the sudden and unexpected recurrence of a pre-existing condition.

A medical illness or injury that you have before you start a new health care plan may be considered a pre-existing condition. Conditions like diabetes, chronic obstructive pulmonary disease (COPD), cancer, and sleep apnea, may be examples of pre-existing health conditions. They tend to be chronic or long-term.

The time period during which a health plan won't pay for care relating to a pre-existing condition. Under a job-based plan, this cannot exceed 12 months for a regular enrollee or 18 months for a late-enrollee.

A pre-existing condition for cat or dog insurance is typically an illness or injury your pet shows signs of any time before the end of your pet insurance waiting period. This may include conditions not yet diagnosed by a veterinarian.

For the purposes of your life insurance cover, a pre-existing medical condition is any illness or injury that exists before, or at the time, you take out a life insurance policy. Examples of pre-existing medical conditions and events include, but are not limited to, the following: Diabetes.