“Not Surprises: Understanding Pre-Existing Conditions in Health Insurance”


One of the most important things to consider when deciding whether to get private health insurance is to have a clear understanding of what a pre-existing condition is and how it affects coverage. Coverage for pre-existing conditions is available AFTER 24 months from the start of the Health Insurance Policy, and each pre-existing condition has coverage up to $8,500. It’s also important to know that pre-existing conditions do not affect the cost of insurance or cause any client to be denied coverage.

A pre-existing condition is any disease, surgery, or condition that the applicant knows about, whether it occurred recently or more than 20 years ago. The length of time the condition has been present is not relevant. Pre-existing conditions can include illnesses such as hypertension, thyroid disorders, and high cholesterol, as well as more serious conditions such as cancer, surgeries resulting from accidents, kidney stones, and even appendicitis.

Here are two examples of what would be considered pre-existing conditions and what would not:

• If someone has had a mole near their right ear since birth and it has not caused any discomfort or grown before purchasing insurance, it is not considered a pre-existing condition.
• If someone has a mole near their right ear and has a history of skin cancer or begins experiencing discomfort before purchasing insurance, it is considered a pre-existing condition.

Determining whether a condition is considered pre-existing or not can be difficult, but clients can rely on their treating physicians to provide reports that explain the onset of symptoms, among other things. These reports are presented to medical auditors of health insurance companies to confirm or rule out pre-existing conditions. It’s recommended that clients declare any diagnosed illnesses or conditions they are aware of so that the insurance company can determine whether or not it is considered pre-existing based on the medical auditors’ evaluations.

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Daniela Cordero


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