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What is considered a pre-existing condition for health insurance?

A brief overview...
  • Pre-existing conditions can be diseases, disabilities or other ailments
  • Each insurer defines pre-existing conditions differently
  • A medical history may qualify as proof of a pre-existing condition
  • Close to half the population has a pre-existing condition
  • Many insurers refuse coverage for pre-existing conditions
  • Insurers charge higher premiums for pre-existing conditions

If you’re shopping for a policy right now, it’s important to understand what’s considered to be a pre-existing condition for health insurance. Simply put, a pre-existing condition is defined by health insurance companies as health-related problems the individual has before applying for the policy coverage.

Traditionally, health insurance companies deny coverage, impose waiting periods or require higher premiums and out-of-pocket costs for individuals who have a pre-existing condition.

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Defining Pre-existing Conditions

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The precise definition of a pre-existing condition can vary considerably among different insurers. Generally speaking, a disorder, ailment, injury, sickness, disease, illness or a nervous, medical or mental issue may qualify as a pre-existing condition if it existed before the first day of coverage. Insurers considered these to be pre-existing conditions, whether or not they have been treated, diagnosed, disclosed, are symptomatic or manifested previously.

Diseases and Pre-existing Conditions

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Some of the common diseases to qualify as pre-existing conditions include diabetes, drug addiction, fatty liver disease and kidney failure, each affecting over 20 million people. At least 17 million people have a history with alcoholism, there are nearly 8 million heart attack survivors and approximately 5 million have a pr-existing Alzheimer’s condition.

Some of the other people affected by diseases identified as pre-existing conditions include over 1 million with AIDS and more than 1.5 million with cancer. Others who are likely to be classified as having a pre-existing condition include over 1.2 million living with Crohn’s Disease, 1.5 million with rheumatoid arthritis and nearly 1 million with a history of having either a pacemaker or stroke.

Other Types of Pre-existing Conditions

Approximately one-quarter of the applicants are seemingly healthy, and still denied coverage based on insurers’ mandates concerning pre-existing conditions.

Obesity is the most common pre-existing condition that is not a disease, affecting almost 40 million adults and more than 12 million children.

Mental health counseling, pregnancy, and intellectual disabilities also qualify as pre-existing conditions, projected to be affecting at least 11 million people in total.

No Coverage for Pre-existing Conditions

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Many insurers do not cover pre-existing conditions identified, treated or recorded to be in existence within the past six months to three years. Taking certain medications, for conditions such as a heart attack, can make policyholders ineligible for coverage for up to 10 years. People who undergo kidney dialysis, treatment for diabetes or surgeries for potentially fatal conditions are typically denied coverage based on having a pre-existing condition as well.

People who undergo kidney dialysis, treatment for diabetes or surgeries for potentially fatal conditions are typically denied coverage based on having a pre-existing condition as well.

Changes Affecting Pre-existing Conditions

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One of the main reasons for implementing the Affordable Care Act throughout the United States was to address how insurance companies managed applicants with pre-existing conditions. Prior to 2014, most insurers sold policies that were medically underwritten, meaning the coverage options offered were based on the evaluation of different risk factors, including health history and health status. The degree of protection retained for people with pre-existing conditions is one of the primary issues associated with the impending repeal and replacement of the ACA.

The degree of protection retained for people with pre-existing conditions is one of the primary issues associated with the impending repeal and replacement of the ACA.

Pre-existing Conditions and the ACA

As of 2014, the ACA began prohibiting insurers from refusing coverage or charging higher premiums for people with pre-existing conditions. Policyholders and their children can no longer be denied coverage for health problems that existed before applying for the health insurance policy.

Approximately 27 percent of the non-elderly population, or over 52 million non-elderly adults, are projected to have pre-existing conditions that would make them uninsurable without the implementation of the ACA.

Approximately 17 million children were denied insurance coverage before the ACA was rolled out.

Pre-existing Conditions Across the U.S.

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In Colorado and Minnesota, only 22 percent of the non-elderly population has pre-existing conditions, the lowest rate in the country. Other states where less than a quarter of the non-elderly adult population have pre-existing conditions include Alaska, California, Connecticut, Hawaii, Iowa, Massachusetts, New Jersey, North Dakota, and Utah.

States with the high rate of pre-existing conditions, accounting for at least of a third of the non-elderly adult population, include West Virginia, Mississippi, Kentucky and Alabama. Generally speaking, the southern states have the highest rate of pre-existing conditions.

Many insurers have the latitude to consider any preventative measure, test or diagnose as grounds for denying coverage due to a pre-existing condition. Approximately 47 percent of the people with pre-existing conditions are typically denied coverage, have their condition excluded or are charged higher premiums by private insurance companies.

People who are uninsurable because of pre-existing health conditions typically end up in the emergency room and have their expenses absorbed by the hospital or Medicaid, resulting in higher healthcare costs for all.

Pre-existing Conditions and Your Healthcare

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Pre-existing conditions affect nearly half of the people looking for insurance coverage, including those that are relatively healthy. Without the ACA, most people with pre-existing conditions are typically denied coverage outright by most private insurers.

For those still able to find an insurer willing to take them on, applicants should still expect to pay higher premiums or have their condition excluded from coverage.

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