Insurance companies use something called underwriting to help work out the risk of insuring you. With health insurance, there are two types of underwriting. Both cover you for new, eligible conditions that crop up after your policy starts, but they deal with pre-existing conditions in different ways.
Full medical underwriting
With full medical underwriting, it’s crystal-clear right from the start if any pre-existing medical conditions are covered or not.
When you apply for cover, you’ll need to fill in a questionnaire about your medical history. Your insurer might also need to speak to your doctor. Once they’ve gathered all the information, they’ll decide what symptoms and conditions they can or can’t cover and let you know.
Choosing full medical underwriting can help speed up the claims process, because your insurer already knows about your medical history.
Moratorium underwriting
With moratorium underwriting, you don’t need to tell your insurer about any pre-existing medical conditions when you apply for cover. Instead, each time you claim they'll look at your medical history to see if it’s a new or pre-existing condition or symptom and if you’re covered for it or not. They may also speak to your doctor.
We don’t normally cover pre-existing conditions, which is any disease, illness, or injury you’ve had symptoms, medication, tests, treatment or advice for in the five years before you take out cover.
However, if you pick moratorium underwriting, we may be able to cover an eligible pre-existing condition after a certain amount of time.From your cover start date, you’ll need to go two continuous years without advice, tests, treatment or medication for your pre-existing condition for us to consider covering it.
So, what does that mean? Let’s say you had treatment for a bad back two years ago. If you take out health insurance with us, this wouldn’t initially be covered, because we’d class it as a pre-existing condition. However, if you go two continuous years from your policy start date with no treatment, diagnostic tests, medication or advice for your back pain, we might then cover it.
FAQs
Firstly, thanks to the Affordable Care Act (ACA), insurers can no longer deny coverage or charge higher premiums based solely on pre-existing conditions. This has dramatically increased access to health insurance for individuals with chronic health issues.
Can you be denied health insurance for pre-existing conditions? ›
Under the Affordable Care Act, health insurance companies can't refuse to cover you or charge you more just because you have a “pre-existing condition” — that is, a health problem you had before the date that new health coverage starts. They also can't charge women more than men.
What is the exclusion period for pre-existing conditions? ›
The time period during which a health plan won't pay for care relating to a pre-existing condition. Under a job-based plan, this cannot exceed 12 months for a regular enrollee or 18 months for a late-enrollee.
What does insurance consider a pre-existing condition? ›
A health problem, like asthma, diabetes, or cancer, you had before the date that new health coverage starts. Insurance companies can't refuse to cover treatment for your pre-existing condition or charge you more.
Does a pre-existing condition have to be diagnosed? ›
How are pre-existing conditions determined? A pre-existing condition is a health issue that required diagnosis or treatment prior to an applicants' enrollment in a health plan.
What pre-existing conditions will not be covered? ›
What are some examples of pre-existing health conditions? Chronic illnesses and medical conditions, including many forms of cancer, diabetes, lupus, epilepsy, and depression may be considered pre-existing conditions. Pregnancy before enrollment is also considered pre-existing and chronic.
What counts as pre-existing medical conditions? ›
What are pre-existing medical conditions? 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.
How far back 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'.
What is the time frame for pre-existing conditions? ›
If you are joining a fully insured group health plan in California, the maximum exclusion period is 6 months. If you are joining a self-insured group health plan, the maximum exclusion period is 12 months. You will receive credit toward your pre-existing condition exclusion period for any previous continuous coverage.
What is a waiver of pre-existing conditions? ›
Simply put, the Waiver of Pre-Existing Medical Conditions covers, or “waives” the companies right to exclude pre-existing medical conditions from their policy. It's a feature only available with certain comprehensive package plans that include trip cancellation/trip interruption.
In the health insurance world, a pre-existing condition is any injury, sickness or condition that exists before the date an insurance policy takes effect. Examples include asthma, diabetes, anxiety, depression, high blood pressure, high cholesterol and so on.
Is a broken bone a pre-existing condition? ›
So what do health insurance companies mean by “pre-existing condition”? A pre-existing condition can refer to the following: A past injury or illness that you have already recovered from (such as a broken ankle from your youth)
What do you mean by waiting period in pre-existing condition? ›
This waiting period is generally imposed if you have a pre-existing condition and have not had prior creditable coverage for a certain amount of time.
Can you be denied for pre-existing conditions? ›
Health insurance companies cannot refuse coverage or charge you more just because you have a “pre-existing condition” — that is, a health problem you had before the date that new health coverage starts.
What is the preexisting condition limitation? ›
A pre-existing condition exclusion period limits the number of benefits that an insurer has to provide for specific medical conditions and does not apply to medical benefits afforded by a health insurance policy for other types of care.
When did preexisting conditions end? ›
Before 2014, some insurance policies would not cover expenses due to pre-existing conditions. These exclusions by the insurance industry were meant to cope with adverse selection by potential customers. Such exclusions have been prohibited since January 1, 2014, by the Patient Protection and Affordable Care Act.
Can you get life insurance if you have a pre-existing illness? ›
Pre-existing conditions can make it more difficult and expensive to get life insurance, but even if you have a chronic or terminal health problem, you can likely find a policy you qualify for if you shop around.
When were pre-existing conditions eliminated? ›
The Affordable Care Act (ACA or “Obamacare”) prohibited pre-existing condition exclusions for all plans beginning January 2014, which was great news for all insurance beneficiaries with pre-existing conditions.
What is the difference between acute onset of pre-existing conditions and pre-existing conditions? ›
Pre-existing conditions are the medical issues themselves, while the acute onset of pre-existing conditions is the sudden and unexpected recurrence of a pre-existing condition.
Can Medicare refuse to cover pre-existing 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.
