Why Pre-Existing Conditions Matter in Insurance

Plans offered to international exchange participants for less than a year of coverage are not fully licensed products so changes to U.S. health laws through the Patient Protection and Affordable Care Act (ACA) do not apply. These plans can increase costs, have pre-existing condition exclusions, or deny enrollment to an individual based on health status.

Generally, a pre-existing condition is any medical condition, injury, or illness that occurred and a licensed physician was consulted or treatment of medication was prescribed, prior to the start date of the insurance policy. The length of time before the start date of coverage during which a condition would be considered pre-existing varies, and can be anywhere from 30 days to 6 months or longer.

A pre-existing condition exclusion waiting period is the length of time after the start date of an insurance policy that a person must wait before any pre-existing conditions are covered. The waiting period is often longer for individually purchased policies.

Did you know that organizations and institutions can negotiate most “short-term duration” accident and sickness group policies? They can negotiate options to:

• Remove exclusions for pre-existing conditions (or other exclusions such as for mental health conditions),
• Reduce the time period defining pre-existing conditions,
• Offer limited coverage to a certain maximum dollar amount for pre-existing conditions or medications,
• Specify coverage in the case of an emergency to stabilize a pre-existing condition, or
• Exclude from the definition of a pre-existing condition, any condition in which one takes a prescribed drug or medicine that remains controlled without any change in a required prescription prior to the start of coverage.

Sometimes a policy that does not explicitly exclude pre-existing conditions or the condition for which treatment is sought such as depression, will instead include language about coverage for “unexpected” reoccurrence or aggravation of a condition. Examples of unforeseen changes that are disability-related conditions might include a need for counseling, or treatment of a bladder infection, blood clot, asthmatic attack, pressure sore or adverse reaction to a medication.

In order to receive coverage, a case would need to be made for why the change was unexpected. The existence of a disability would need to be clearly distinguished from the cause of an illness or injury abroad that is related to the environment (climate, activity, food, etc.) or from difficulty accessing care abroad in exasperating (i.e. making worse) the condition.