Are Pre-existing Conditions Ever Covered?

Though there are almost as many definitions of “pre-existing condition” as there are policies, a pre-existing condition generally means any medical condition, diagnosed or not, which exhibited symptoms, or was treated or investigated by a physician or required medication within a specified period prior to the date of insurance. That period could be 30 days, 90, or a year—it depends on the policy. So if you have been experiencing sharp abdominal pains for two or three weeks before leaving on your vacation, but your gall bladder was not removed until after you arrived in Florida, that’s a pre-existing condition, whether or not it was diagnosed or treated by your family physician.

It’s not necessary for a formal diagnosis with clinical terminology to be recorded in a doctor’s notes for a pre-existing condition to be recognized. Common sense has a role to play in such determinations too.

Pre-existing conditions may or may not be covered, depending on the type of policy you buy. Some simply state that pre-existing conditions are Not Covered. Period. Or they may specify no coverage of pre-existing conditions that occurred within the past five years, or one year, or 90 days, or ever. Plans for people without pre-existing conditions are the cheapest, especially for super healthy people who never see a doctor except for a routine physical. But for the rest of us there are plenty of other options.

Many plans say they will cover pre-existing conditions. But don’t take that at face value. Read the fine print. Nobody covers pre-existing conditions unconditionally.

Insurers who say they cover pre-existing conditions will do so only if those conditions are stable and controlled. This is how the Travel Health Insurance Association defines this term:
“Stable and Controlled means the medical condition is not worsening and there has been no alteration in any medication for the condition or its usage or dosage, nor any treatment, prescribed or recommended by a physician, or received, within the period specified in this policy before the trip in question.” Whew!

In short, any pre-existing condition that exhibited symptoms, required treatment or a change of medication prior to the effective date of your insurance will very likely be considered “unstable” and will not be covered. Even a change of dosage of the same drug may be considered an instability, so be watchful and understand what your physician is prescribing for you. Usually, shifting from a trade product to a generic of the same strength should not adversely affect your stability status. But if your insurer gives you a problem on that point, you have justification for a complaint. (We’ll deal with complaints later).

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