What determines preexisting condition?
Asked by: Eden Fritsch | Last update: October 23, 2025Score: 4.8/5 (43 votes)
What qualifies as a pre-existing condition?
Any condition (either physical or mental) including a disability for which medical advice, diagnosis, care, or treatment was recommended or received within the 6-month period ending on your enrollment date in a health insurance plan.
What counts as a pre-existing health condition?
It applies to any medical condition that you saw your doctor about the five years before the start date on your health insurance. For example, you might take out a policy and then go and see your GP about some back pain you've been experiencing.
How long ago is a pre-existing condition?
A pre-existing medical condition is a disease, illness or injury for which you have received medication, advice or treatment or had any symptoms (whether the condition has been diagnosed or not) in the five years before your joining date. Health insurance doesn't usually cover 'pre-existing conditions'.
How far back does pre-existing condition last?
A group health plan can count as pre-existing conditions only those conditions for which you actually received (or were recommended to receive) a diagnosis, treatment or medical advice within the 6 months immediately before you joined that plan. This period is known as the “look back” period.
What Is a Pre-existing Condition?
What is the usual minimum waiting period for a pre-existing condition?
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.
Is a bad back a pre-existing medical condition?
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.
Can preexisting conditions be denied?
Coverage for pre-existing conditions
No insurance plan can reject you, charge you more, or refuse to pay for essential health benefits for any condition you had before your coverage started. Once you're enrolled, the plan can't deny you coverage or raise your rates based only on your health.
What is the waiting period for pre-existing disease?
Almost all health insurance plans cover pre-existing diseases after a waiting period of usually 2 to 3 years. This implies that any hospitalization expenses related to the declared ailments can be claimed only after 2 to 3 successful years with the insurer.
Is high blood pressure considered a pre-existing condition?
Insurers generally define what constitutes a pre-existing condition. Some are obvious, like currently having heart disease or cancer. Others are less so – such has having asthma or high blood pressure.
Is high cholesterol considered a pre-existing condition?
Does high cholesterol count as a pre-existing medical condition? Yes. High cholesterol is considered a pre-existing medical condition by insurance companies, along with similar conditions like high blood pressure.
What pre-existing conditions are not covered by life insurance?
- Anxiety and depression.
- Asthma.
- Diabetes.
- Heart disease.
- High blood pressure.
- High cholesterol.
- HIV.
- Obesity.
Is a broken leg a pre-existing condition?
Pre-existing conditions can include serious illnesses, such as cancer. It can also include less serious conditions, such as a broken leg, and in some cases, even prescription drugs can count as a pre-existing condition.
What counts as a pre-existing medical condition?
What is a pre-existing medical condition? It's any medical problem you've had before applying for private health cover. These can be: physical health conditions.
Can Medicare deny coverage for preexisting conditions?
Does Medicare Advantage cover preexisting conditions? Yes. Medicare Advantage (MA) plans won't reject your enrollment if you have a preexisting condition. But since MA plans are offered by private insurance companies, coverage levels and costs can vary from company to company.
Is GERD a pre-existing condition?
It may, as GERD is considered a pre-existing condition and could potentially lead to higher premiums or difficulty finding coverage. However, each insurance company has their own underwriting guidelines and some may not consider GERD to be a significant risk factor.
How do insurance companies determine pre-existing conditions?
To determine if a condition is pre-existing, insurers examine medical history, treatment records, and diagnosis reports. They may use “look-back periods,” which are specific timeframes—typically six months to a year before coverage begins—to review medical history.
How soon after getting insurance can you get surgery?
Depending on your provider, insurance companies can take anywhere between 1-30 days to approve the request. Stay in communication with your care team, as timing for approval varies between insurance providers.
How long is something considered a pre-existing condition?
The plan was allowed to look back at the previous six months of the person's medical history, and exclude pre-existing conditions that were treated during that six months, with the exclusion period lasting no more than 12 months.
Why doesn't insurance cover pre-existing conditions?
If you are enrolled in a plan since 2010, then your insurer can't legally deny you coverage or charge you higher premiums because you have a pre-existing condition. The Affordable Care Act, passed in 2010, made it illegal for insurers to deny you coverage or charge high rates for pre-existing conditions.
What is a pre-existing condition in 2024?
A health insurance company will consider any condition where you have been diagnosed, experienced symptoms, or received treatment as being 'pre-existing'. Most of the time this will only apply to conditions from within the last 5 years, so you wouldn't need to disclose conditions from before then.
Can I buy health insurance and use it immediately?
Many, but not all, short term health insurance plans can take effect the day after your application is received.
What is the exclusion period for pre-existing conditions?
A pre-existing condition exclusion can not be longer than 12 months from your enrollment date (18 months for a late enrollee).
Is a herniated disc considered a preexisting condition?
A pre-existing condition is typically defined as a health issue that existed before the accident or injury in question. Insurance companies and defense attorneys often argue that if the injured person had a disc herniation before the accident, it should not be considered a new injury.