When insurance companies refuse to pay a claim for a pre-existing condition, it feels like a punch in the gut. You’ve paid your premiums, you’re hurt, and you need help — but instead, you’ve been turned down because of a health condition that existed before the accident.
Insurance companies frequently use the pre-existing condition argument to deny people compensation after an accident, even when that argument doesn’t hold water. While it’s true that insurance companies can deny accident claims for pre-existing conditions, they sometimes stretch the definition of a pre-existing condition or won’t pay up when an accident aggravates a prior injury. If this happened to you, it’s time to call an attorney. The Fort Walton Beach personal injury lawyers at The Bruner Law Firm have helped many people like you battle insurance companies, and this blog explains when an insurer can or can’t deny a claim based on a pre-existing condition.
What Is a Pre-Existing Condition?
In simple terms, a pre-existing condition is any health issue you have before your insurance coverage starts. This could be something major like diabetes or heart disease or something minor like an old ankle sprain.
It’s important to remember that having a pre-existing condition doesn’t mean that you’re uninsurable or that every claim will automatically be denied. But it can certainly make things more complicated when you’re trying to file a claim, especially after a personal injury.
Can I Recover Compensation for a Pre-Existing Condition?
In the world of personal injury law, there’s a principle known as the “eggshell plaintiff” rule. This rule essentially states anyone injuring another person is responsible for all the consequences, even if the person had a pre-existing condition that worsened the injuries. Sounds fair, right?
In theory, this should mean pre-existing conditions shouldn’t impact your right to compensation following an accident. But in reality, it’s not always that straightforward.
Insurance companies are businesses; like all businesses, they’re trying to minimize costs. Sometimes, they might argue that your injury resulted from a pre-existing condition rather than the accident. And in those cases, they might attempt to deny your claim or reduce the amount they have to pay. But remember, just because an insurance company says something doesn’t mean it’s the final word.
How to Prove Your Injury Wasn’t a Pre-Existing Condition
If your claim gets denied due to a pre-existing condition, it might feel like you’ve hit a brick wall. But don’t worry; you can take steps to challenge the insurance company’s decision. It begins by demonstrating that a pre-existing condition did not cause your injury but is a result of the accident. Here’s how you can do that:
- Medical Records: Your medical records are your most powerful tool to push back against an insurance company’s ruling. These records can show the state of your health before and after the accident. If your records indicate that your condition worsened significantly after the accident, they can serve as strong evidence that the injury resulted from the accident, not the pre-existing condition.
- Doctor’s Opinion: A doctor or medical expert can provide a professional opinion on whether the accident could have caused or aggravated your injury.
- Accident Reports: If there were witnesses to your accident or if there’s a police report, these can also help establish the cause of your injury. If the reports indicate you were injured in the accident, this can support your claim.
- Timeline: Showing a timeline of your medical treatment can also be helpful. If you sought medical attention immediately after your accident, it can help link your injury to the incident.
What If an Accident Aggravated My Pre-Existing Condition?
If an accident worsens your existing condition, it’s likely you can still recover compensation. This is a continuation of the “eggshell plaintiff” rule we discussed earlier.
Just like an eggshell is more fragile and likely to crack, some people might be more susceptible to injury. But the law acknowledges this and, as a result, you shouldn’t be penalized because you had a pre-existing condition that made you more vulnerable to injury.
Suppose you had a previous back injury that hadn’t bothered you for years. Then, because of a car accident, you’re suddenly dealing with terrible back pain again. This is an example of an accident aggravating a pre-existing condition. Even though your back wasn’t in perfect shape beforehand, the accident made it worse, and the at-fault party could be responsible for that.
It’s crucial, however, to prove that the accident aggravated your pre-existing condition, which goes back to having good medical documentation, expert opinions, and a detailed timeline of your symptoms and treatments.
While insurance companies technically can deny claims for pre-existing conditions, they frequently exploit this loophole for their own gain and to deny people the money they need. If an insurance company won’t pay your claim because of a pre-existing condition, call (850) 243-2222 or fill out our contact form to speak with one of our attorneys.
Related Posts:
- How Are Personal Injury Settlements Paid Out?
- What Not to Say to an Insurance Adjuster
FAQs
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.
What type of insurance can be denied due to pre-existing conditions? ›
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.
Why can't pre-existing claims be denied? ›
Under federal law, a health insurance company cannot refuse to cover you or charge you more based on a pre-existing condition. A “pre-existing condition” is a health problem you had before the date your new coverage starts.
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 qualifies as 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.
Can people with preexisting health conditions no longer be denied coverage? ›
Health insurers can no longer charge more or deny coverage to you or your child because of a pre-existing health condition like asthma, diabetes, or cancer, as well as pregnancy. They cannot limit benefits for that condition either.
What if pre-existing conditions are not declared? ›
Failure to disclose pre-existing conditions not only jeopardizes the chances of successful claims but may also lead to the cancellation of the policy in extreme cases.
What is a typical reason for a denied claim? ›
Incorrect or duplicate claims, lack of medical necessity or supporting documentation, and claims filed after the required timeframe are common reasons for denials. Experimental, investigational, or non-covered services are also likely to be denied.
What counts as 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.
What is a frequent reason for an insurance claim to be rejected? ›
Incorrect or Missing Patient Information
Many claim denials start at the front desk. Manual errors and patient data oversights such as missing or incorrect patient subscriber number, missing date of birth and insurance ineligibility can cause a claim to be denied.
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 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.
What is the proper response to a failure to obtain preauthorization denial? ›
The proper response to a failure to obtain preauthorization denial is to request a retrospective review. This type of review occurs after the medical service has been provided, and it involves the insurance company evaluating the claim to determine if it meets the necessary criteria for coverage.
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.
Is back pain a pre-existing condition? ›
Examples of pre-existing conditions
Here are a few examples of conditions that may be considered as pre-existing by your insurer: Chronic pain such as back pain, neck pain… Cardiovascular conditions such as hypertension, high cholesterol... Cancers.
Does being pregnant count as a pre-existing condition? ›
According to Healthcare.gov, pregnancy is not considered a pre-existing condition. So if you were pregnant at the time that you applied for new health coverage: You can't be denied coverage due to your pregnancy. You can't be charged a higher premium because of your pregnancy.
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.
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.
What is pre-existing denial? ›
Today, insurers cannot deny coverage to somebody based on pre-existing conditions, nor charge more. A pre-existing condition is any health problem or ailment that was previously diagnosed at the time of applying for coverage.
Does critical illness insurance cover pre-existing conditions? ›
Many insurance policies might not cover a pre-existing condition. For example, if you had cancer in the past, the critical illness policy might not cover cancer if it comes back. But it might cover another critical illness, like a heart attack or stroke, that occurs while you have the policy.
If your claim gets denied due to a pre-existing condition, it might feel like you’ve hit a brick wall. But don’t worry; you can take steps to challenge the insurance company’s decision. It begins by demonstrating that a pre-existing condition did not cause your injury but is a result of the accident. Here’s how you can do that: