What qualifies as a prexisting condition?

August 16, 2009 3:29 PM

What exactly qualifies as a preexisting condition? Do/did I have one?

I've been hearing a lot on Mefi and elsewhere lately about how health insurance companies sometimes deny coverage because of a preexisting condition, and I'm trying to get a handle on how pernicious this practice is. Fortunately for me, I'm part of a group plan provided to graduate students at my university, which two years ago paid for my surgery to have a nasopharyngeal angiofibroma (a benign growth that was blocking up my nose) removed. The doctor told me that the mass had likely been growing for many years.

1. If I had started on a private plan during that time the mass was growing, could I have been denied coverage because this was a preexisting condition?

2. I've had several check-ups since the surgery. There is no sign of the mass returning, and my doctor says it is very unlikely that it ever will. Could I be denied private health insurance or have to pay higher rates because of having had the growth? If something else unrelated goes wrong with my nose, how likely would it be that I would be denied coverage because of having previously had this mass?

I know it's unlikely that others have had the exact same medical condition; I would be curious to hear what conditions you have had that lead to denial of coverage (or not) by private insurance companies.

(Needless to say, I'm an American.)

posted by Tsuga to health & fitness (7 comments total)

You might find this HIPAA fact sheet useful. HIPAA is pretty recent.
posted by gensubuser at 3:32 PM on August 16

I've had it explained to me that there has to be a prior medical diagnosis for it to be a preexisting condition. Insurance companies can reach as far as what a "diagnosis" is, like they might point to your being treated for nasal allergies previously or something and say that that was proof you already had the condition or some b.s. like that. However, usually it would mean that if say, you had asthma, but it had never been diagnosed before, and you were diagnosed while on your health insurance, that would not be a preexisting condition for that health insurance. Again, that was just how someone explained it to me, and is not an all encompassing answer for all situations.

There are also various rules as to how far certain insurance plans can look back in your health history to find preexisting conditions.

In addition, as long as you have not had a gap of coverage of more than 63 days, most types of group plans cannot look at preexisting conditions, not sure about individual ones.
posted by ishotjr at 4:09 PM on August 16

Pretty much anything you have ever been diagnosed with is considered a pre-existing condition. This seems to include allergies, colds, etc. You are expected to disclose every single thing that has ever happened with a doctor over the past 5 years (including all routine appointments) or so when applying for private coverage.

However, this doesn't seem to impact your rates for most insurers; they just won't cover any conditions or anything even tangentially related to your condition for 6-18 months. You might be out of luck for things like allergies and head colds for some time on private insurance since your condition is related to your nose.

I do not believe HIPPA has anything whatsoever to do with private insurance.
posted by shownomercy at 4:42 PM on August 16

As someone who has two things which generally qualify as "pre-existing conditions," the only real answer is "it depends on the rules of your insurance plan."

In my case, it was something like "any condition for which you have been treated or sought treatment in the last 12 months," and the exclusion only applied if I'd had a gap in coverage of over 60 days.

My plan wouldn't fully deny me coverage due to them (they can't, since it's a group plan), but they could deny coverage for anything directly related to those conditions for 12 months.

If you're looking for private insurance, however, they can and will deny you a policy for such things, depending on their severity. For a broken ankle, they probably just won't cover anything that happens to your ankle for the next 12 months. For cancer, they probably won't offer you a policy.
posted by CrayDrygu at 8:50 PM on August 16

Thanks for the answers. I've never had to think too hard about insurance--growing up I was covered by my parents' plan, then I had private insurance for a few years during which I had no health issues to speak of, then my insurance as a grad student--but some of the health insurance horror stories I've read lately were making me worry.
posted by Tsuga at 10:03 PM on August 16

Last spring I applied for and became covered under and individual health insurance plan (constrasted with a group insurance plan, which would be through an employer or school). Then, in July, I was diagnosed with a condition that I probably had before getting the new insurance, but did not know about. Even though the condition probably existed before I got this insurance coverage, it was undiagnosed and therefore does NOT count as a pre-existing condition.

On the other hand, if I had been diagnosed with this condition BEFORE applying for individual insurance, it's likely that I would have been denied coverage due to the pre-existing condition. I may have been able to qualify for a more expensive individual plan, but there's no guarantee that I would have been accepted.

Now that I have this diagnosis, it is unlikely that I would be able to get affordable individual coverage if I was trying to switch insurance companies. However, if I start graduate school or get a job, I would be able to join the group insurance plan through my school or employer because group plans are not allowed to deny coverage based on a pre-existing condition. They will still call it a pre-existing condition though.

So say I do that, join a group plan even though I have this pre-existing condition. As long as I have continuously been covered by health insurance for the last X years, they will pay for treatments related to my pre-existing condition. However, if I had had a gap in coverage of more than 60 days (like if I stopped paying my insurance bills or something) in my recent past, then this new insurance could initially refuse to pay for any treatment related to my pre-existing condition. This is called a "pre-existing condition limitation". (People often throw around the term "pre-existing condition" when they mean "pre-existing condition limitation", which leads to a lot of confusion.) After I had been insured by the group plan for a specified amount of time (typically 6 or 12 months), then they would start covering treatment for my pre-existing condition.

Luckily, I've found that many graduate schools contract with providers of individual health insurance policies to provide continuation coverage for their students after graduation, without any pre-existing condition limitations. That means I can get affordable, individual health insurance after graduation even if I don't have a job lined up yet. As you might have gathered from the above, avoiding any lapses in coverage is REALLY important to avoid getting screwed over later.

I would definitely recommend contacting the student health benefits office at your school to ask about continuation coverage after graduation - what do they offer, when are the deadlines for signing up, etc.

I do not believe HIPPA has anything whatsoever to do with private insurance.

This is not true.
posted by vytae at 9:06 AM on August 17

Also, please note that any insured person in the U.S. who isn't insured by the government (so, anyone not on Medicare/Medicaid, VA benefits, or a state program) has private insurance. The distinction between what you get from your job/school vs. what you'd get all by yourself is between a group plan and an individual plan. These are both private insurance.
posted by vytae at 9:08 AM on August 17