A pre-existing condition is any personal illness or health condition that existed prior to enrolling in insurance.  Health or life insurance policies often identify customers pre-existing conditions before enrolling a person in insurance. Most companies did not cover pre-existing conditions until a specific period of time passed. However, when the Affordable Care Act passed, it prevented many companies from doing that.

Pre-Existing Conditions

Pre-existing conditions are usually identified under the objective standard definition which is when the patient has already received medical advice or treatment prior to an enrollment in a new medical or life insurance policy. Another definition used to define pre-existing conditions is the broader prudent person definition. This is when symptoms were present and a prudent person would have sought treatment.

Examples

What is a pre-existing condition? The following is a list of what can/ or could be considered a pre-existing condition:

  • AIDS/HIV
  • Cancer
  • Cerebral Palsy
  • Anxiety/Depression
  • Alzheimer’s
  • Dementia
  • Diabetes
  • Heart Disease
  • Obesity
  • Pregnancy
  • Pending Surgery
  • Sleep Apnea
  • Stroke

Even a more minor health condition such as acne, tonsillitis, high blood pressure, or menstrual period irregularities could be considered a health issue, depending on the provider.

Does Insurance Cover Them?

Under current law, health insurance companies can’t refuse to cover you or charge you more because of a pre-existing condition.  This began for plans effective on or after January 1, 2014.  The pre-existing coverage rule does not apply grandfathered individual health insurance policies. A grandfathered individual health insurance policy is a policy that was purchased for yourself or your family on or before March 23, 2010.

Affordable Care Act

Prior to the Affordable Care Act, insurance companies denied millions of women coverage due to a range of health issues labeled as pre-existing health issues such as pregnancy, breast cancer, and irregular periods. Black and Latino women faced higher rates of many chronic illnesses. Women who had a cesarean section were likely to have 25% higher premiums with some companies. One in eight women have breast cancer and some insurances still considered it a pre-existing condition. African American women are most likely to develop the disease and are most likely overall to die from the disease. Without the ACA, women who needed mental health treatment could pay as much as $9,000 a year just for that care alone.

Declinable Conditions

In 2018 it was estimated that around 54 million non-elderly adults in the United States had “declinable” pre-existing conditions that would have made them uninsurable. Declinable conditions were identified by an analysis of health insurer underwriting manuals. Obviously not all of these 54 million people buy health insurance coverage, but the individual market is where people go when they are between jobs that offer health benefits and ineligible for public plan coverage such as Medicare or Medicaid. If it would revert to medically underwritten coverage, as it was prior to the ACA in most states, these 54 million people could be uninsurable if they were laid off from their job and then lost their job-based health benefits.