Which Pre-existing Conditions Are Not Covered?

Background: What’s a Pre-existing condition?

For insurance purposes, a pre-existing condition is any medical condition or diagnosis you had prior to the issuance of an insurance policy. What pre-existing conditions, if any, are covered by the policy varies from policy to policy. Some insurance policies are affected by government regulations, such as the Affordable Care Act (“Obamacare.”) Some policies have a clause that excludes any condition (diagnosis) that existed at the time the policy was issued, even if it was not discovered until after the diagnosis was established. 

Three examples (among many) are diabetes, kidney failure, and coronary artery disease. All three of these may be present for years before any symptoms appear and may not even be suspected by your doctor until they show up as an “incidental finding” on lab tests. Your policy may exclude these if there is evidence that they existed before the issuance of the policy. Other policies do not exclude conditions that are diagnosed after the issuance of the policy even if there is evidence that they were present before the diagnosis. The simplest answer is “it depends.”

The Affordable Care Act placed many restrictions on exclusion of pre-existing conditions. Polices sold on the Federal or state insurance exchanges (see the Federal Health Insurance Exchange) The Trump administration approved the issuance of policies providing coverage for up to one year that exclude pre-existing conditions. 

What Can I Do About This?

If you’re aware that you have a pre-existing condition that either requires current treatment or is likely to require treatment while you have the policy, your best bet is to consult an insurance broker who represents multiple companies. They may be able to identify a policy for you that does not exclude the conditions you know you have. And, of course, you can always appeal a denial of coverage using the mechanism for appeals provided by your policy. Be aware, however, that insurance companies vet their policies with their lawyers and the denial of pre-existing conditions is likely to be ironclad. 

Another approach requires the cooperation of you provider. New symptoms may arise from a pre-existing condition. Suppose you have had back trouble for years. A symptom which has the diagnosis “pseudo-claudication syndrome” may appear. In this condition, you have the same pains you would have if you had blood vessel disease, but the pain is coming from your spine, not your blood vessels. While this flows from a pre-existing condition, it is new. Depending on how their computers for processing claims are programmed, the insurance company may pay this. It may not. It totally depends on the wording of the policy and how strictly the insurance company enforces it. Make your provider aware of your pre-existing condition and your insurance situation and see if they can bill the insurance company with a new (but valid) diagnosis. 

It May Depend on Where You Live

Insurance is generally regulated by the states. Your state may have restriction on the exclusion of pre-existing conditions. You can check with your state’s insurance department. A list of all state insurance commissioners may be found at State Insurance Commissioners.  

What Plans or Situations Do Not Exclude Pre-existing Conditions?

Insurance laws or company policies may restrict or eliminate non-coverage or pre-existing conditions. 

  • Medicare and Medicaid do not exclude them. 
  • Policies issued under Obamacare cannot exclude them. 
  • Medicare supplemental policies (“Medigap”) can exclude pre-existing conditions for only for the first six months if you enroll in the Medigap Open Enrollment period, which starts when you first get Medicare and enroll in Part B (coverage for all services other than inpatient hospitals.) This period lasts for six months.
  • Outside of that period, Medigap policies can exclude pre-existing conditions permanently. 
  • Other policies may cover pre-existing conditions after a waiting period. 
  • Medicare Advantage (Part C) generally cannot exclude pre-existing conditions. 
  • Medicare Special Needs Plans, which are a type of Medicare Advantage plan. These plans cover the following conditions even if they were pre-existing: chronic alcoholism, drug addiction, cardiovascular disorders, chronic heart failure, diabetes, end-stage liver disease, end-stage renal disease requiring dialysis, HIV/AIDS, chronic lung disorders, chronic and disabling behavioral health conditions, dementia, severe blood disorders, and stroke. You can enroll in a Medicare Special Needs Plan at any time. 

What Should I Do Now?

Your wisest course, whether or not you have a pre-existing condition, is to consult an insurance broker such as those at HealthCareInsurance.Company. You can reach them through their web site or at (855) 401-8383.