Exactly what is a "pre-existing condition"?

[Raven]

I have a friend who just came through breast cancer surgery. I am fairly sure that she would have a "pre-existing condition." But what about people on blood pressure or cholerestol medication or people who smoke or smoked in the past? Is aging a "pre-existing condition"? How, exactly, is this term defined?

[Brickbat]

1. It's not, IIRC. Private companies get to decide what it is. Convenient, eh?

[napi21]

2. One insurance co. canceled someone's ins because they

failed to disclose having severe acne as a teen. They considered THAT a PEC! I think the definition is whatever the ins. co. can think of next!

[Sheepshank]

48. Infertility is considered a PEC in some areas

...even if one is not seeking treatment to get pg.

[Posteritatis]

3. They're better known as "the slightest excuse as desired," really

If they could get away with defining aging as one they would, considering in eight states being beaten by one's spouse qualifies.

[hayu_lol]

6. We are all together on this page...

must be experiences we've had with healthcare providers/other insurance cos.

[Odin2005]

4. An excuse.

[lunatica]

5. It's whatever the health insurance people say it is

There is nothing anywhere to define it legally. This is a major reason why this whole Health Care reform is happening. If a kid is born with some crippling disease or lifelong condition that will need medical care insurance companies can refuse to treatment based on 'pre-existing' conditions. It doesn't matter if you've been paying your premiums for years. They can simply say no coverage for care. It's arbitrary and based on the bottom line and profit.

[enlightenment]

7. I think it's anything that the insurance companies want to define

as pre-existing.

If you were treated for any condition that could reoccur (from cancer to depression to reflux) you potentially have a pre-existing condition. Of course, they can also simply refuse you coverage because you haven't seen a doctor in years, since the presumption is that you undoubtedly have some sort of medical problem.

[dkf]

8. I've seen some crazy uses of that clause.

Wasn't someone terminated for not having reported pulling a muscle?

[dflprincess]

9. A preexisting condition is anything the insurance company wants it to be

in order to avoid paying claims.

Are you in your 50s and just diagnosed with cancer? Wait - you forgot to tell your insurer that you were treated for acne 40 years ago? They may decide you have a preexisting conditon and they will deny your claims.

[Mz Pip]

10. Anything the insurance companies say

it is. I know a 23 year old woman who was denied because she'd had surgery on a bone spur a couple of years before when she was doing a lot of ballet.

A pre-existing condition can be a f*cking bone spur.

Mz Pip

[stray cat]

11. Life?

[golddigger]

12. Being alive!

[csziggy]

13. Anything that gives the insurance companies an excuse not to cover people

That they think might cost them a dime. A few pounds overweight, any kind of previous illness, injury, or condition - doesn't matter.

[Journeyman]

14. My daughter was born with a "pre-existing condition". . .

She needed surgery to correct it but was denied when we submitted the papers.

"Pre-existing condition?" I asked. "I don't remember needing paperwork for my wife to get pregnant!"

Fortunately, I'm related to an attorney who knew his way around insurance companies. He wrote a letter and managed to get the insurance company to pay.

I was lucky. If I hadn't been related to an attorney, I wouldn't have been able to afford the minimal work he did for me. And as the insurance company rolled over so easily, I wonder, how often do insurance companies routinely deny coverage, confident a large percentage of their clients will simply give in and give up.

Born with a "pre-existing condition." What rubbish.

[MineralMan]

15. We're all born with a pre-existing condition that

is terminal. We're human.

[Posteritatis]

40. Don't forget that damned oxygen dependency. Addicts from conception on, all of us! (nt)

[jtrockville]

16. It's a "Uniquely American" term, that's for sure.

Developed nations have no need to define such a term.

[livetohike]

17. I've had migraine headaches my whole life

I completed my application for health insurance (we're self insured) and listed that I have been treated for migraines. Guess what?

It's a pre-existing condition and I was placed in a higher "tier" than my husband which means I pay more due to my pre-existing condition. Never mind that I haven't had a migraine in three years since I am post-menopausal and they seem to have disappeared.

[WillowTree]

18. A pre-existing condition is any condition...

....for which a person has received treatment, including medication, or medical advice prior to applying for insurance. Maintenance meds such as those for hypertension or high cholesterol aren't prescribed for people who don't have those conditions, so that's kind of a DUH, right?

The pre-existing conditions rules also usually include wording to exclude conditions for which a prudent person would have sought treatment. In other words, if you had a 2cm growth on your hand which had been there for a period of time (which it would have to have been.......a lesion that size doesn't spring-up overnight), or a bleeding ulcer (of which there would necessarily have been serious symptoms) and didn't have it looked at until after your insurance went into effect, that would be considered a pre-existing condition, too.

Smoking is not treated as a pre-existing condition, but rates for individual medical insurance policies are usually surcharged for smokers since it does increase the risk of serious health issues. If you quit over a year prior to applying for insurance, the surcharge is usually waived, however.

[elehhhhna]

19. it's worse than that -- some companies have efined per-existing as

any SYMPTOMS you may have suffered and never had diagnosed or treated.

Also, I got flat out turned down for LTD coverage due to a minor, easily treated case of post-partum depression I'd suffered 10 years prior to applying.

[RB TexLa]

21. Something a reasonable person would have had check out is a pre-existing

condition. You can't have a huge lump under your arm for a year, go buy insurance, get it checked out the next day find out it's cancer, tell the insurance company you just never noticed it, didn't know about it and expect the insurance company to cover your cancer.

[Generic Other]

20. My parents had no sense of humor

Is that a pre-existing condition?

[Mitzo1310]

22. Sleep apnea, for one.

An allergist sent me to a sleep clinic that subsequently diagnosed me with "moderately severe sleep apnea". I didn't even know I had it, yet I was prescribed one of those ridiculous CPAP machines, which I subsequently ditched after four months of pure hell. That was two years ago, when I was employed. Unemployed and in need of a comprehensive health insurance plan, I was recently denied coverage by Blue Cross Blue Shield because of my "untreated" sleep apnea.

I say this with complete sincerity and with no malice, but those of you who support this current clusterf*ck called insurance reform have chosen to give the health insurance industry more power. Reform starts by eliminating tax breaks for employer provided health insurance. How many people expect their employer to pay for their auto insurance...or their rent, for that matter? True reform will only happen when the health insurance industry is completely removed from the health care equation. Anything else is completely unacceptable.

[Fire_Medic_Dave]

25. Untreated moderately severe sleep apnea is a very serious condition.

BCBS denying you insurance was reasonable.

[Mitzo1310]

32. "Reasonable" this...

A second medical opinion.

The diagnosis was made with me sleeping on my back; a myriad of attached wires and electrodes ultimately determining how the test was performed. I'm a side sleeper. What about stomach sleepers? How many others are out there like me? That was never taken into account in the diagnosis. Rigged results? Kickbacks to doctors investing in sleep clinics? These are possibilities that will never be analyzed by a nurse (or a medic) whose job is to help insurance companies deny coverage.

So, Mr. Smarty Pants, are you pleased that insurance companies employ medical hacks to help them deny coverage to those willing to pay for it?

[Fire_Medic_Dave]

41. Why did you sleep on your back? You are supposed to sleep as you normally do.

Denying people who refuse to adhere to treatment regimens is smart business as the system is set up right now. Should the system be set up differently of course it should. Do you have any evidence that medics are used to deny insurance? Please produce it if you do.

[hfojvt]

37. welcome to DU

but removing tax breaks for employer provided health insurance, although it is probably fair, is politically impossible, the voters who lost their tax benefits would be furious.

[Fire_Medic_Dave]

23. Any condition that you have previously been diagnosed with. Pretty simple really.

[dysfunctional press]

29. and diagnosed with by an md.

i was uninsured when my ankylosing spondylitis was diagnosed by a chiropractor...before taking my bones to a regular doctor, i got insurance.
within two years, they were switching our due date all around, and then cancelled me when they said that the payment arrived a day too late.
and before you ask- this was before there was such a thing as online billing.

[Fire_Medic_Dave]

42. I'm pretty sure a diagnosis by a Nurse Practitioner, PA or chiropractor would suffice.

[dysfunctional press]

46. it didn't in my case.

and the insurance application never asked about chiropractor visits.
this was also awhile back- things may have changed as far as recognition of pseudo-medicine. :shrug:

[Fire_Medic_Dave]

50. I'm glad it worked out.

[Kablooie]

24. And if you have a large claim they can find previously unreported PEC and refuse to pay.

In at least one case, after they paid the hospitals, THEN they found a PEC and made the hospitals return the payments.
The customer was then on the hook for everything that had previously been paid for.

[Greyhound]

26. Insurance Corporations; "Anything we say". n/t

[salguine]

27. A pre-existing condition is about to be redefined as "whatever the insurance company says it is."

[Fire1]

28. What's the point of this OP, if you can't get cancelled due to a

"pre-existing condition?" IOW, why should anyone care what it is? This sounds like fabrication and flamebait. :thumbsdown:

[havocmom]

34. It matters because they jack up rates

Not flamebait, but sound question. Dissing it is Crap and one wonders if it is paid crap.

[Fire1]

35. I'll go with Axelrod in saying no ones coverage will exceed

8%, over your wild speculations, any day. Btw, I wish the hell I was being paid. Still sounds like fabrication and flame bait.

[havocmom]

36. LOL I'll go with the reports of people dealing with outrageous rate hikes over a pol's word

:rofl:

[Fire1]

38. Past rate hikes, that is. Just looked at my coverage for Januay

and mine actually went DOWN with the same identical coverage and the bill hasn't even been signed, yet!!! :rofl:

[havocmom]

39. Most worker bees ALREADY pay over 8% IF they can get it at all

Congrats on your savings. Take the money and help a senior or single parent with it. The horror stories are legion and looking at my own bill, not all that unique

I would love to believe Axlerod, but have lived long enough to know better.

[Deja Q]

30. Being born (no wonder they're keeping abortion out of the proceedings)

[quaker bill]

31. A pregnancy

in the case of the birth of my daughter.

[WillowTree]

44. Nonsense, unless....

...you purchased insurance when you were already pregnant and then expected the insurance policy to cover it. That would be like buying homeowners insurance after the house is already on fire thinking the insurance company is going to rebuild your house for you.

[NNN0LHI]

33. Being born overweight or underweight can be considered a pre-existing condition

[NMMNG]

43. Being alive

I can't get insurance because I have migraines, which require medication--rather costly medication. Insurance corporations only want people who will pay premiums without ever making claims. How else will their CEOs maintain their multimillion dollar/year salaries?


You wouldn't believe some of the "pre-existing conditions" or medications that can disqualify you for insurance coverage. It's a vile, disgusting scam.

[walldude]

45. Thanks for that link... Informative to say the lease.

:toast:

[dysfunctional press]

47. whatever the insurance company needs it to be, in order to deny a claim.

but that's just the dictionary definition, mind you.

[Blasphemer]

49. All of the above... anything that means you require medical care is a pre-existing condition.. nt

[McCamy Taylor]

51. Whatever the insurers want it to be when they decide to drop you.

[DailyGrind51]

52. Acne can be considered a "pre-existing condition" and has.

"Individual Health Insurance
And Pre-Existing Conditions



On the individual health insurance side a pre-existing condition is defined very differently. Again, keep in mind that this can vary from company to company and from state to state but with most insurance companies (meaning big reputable companies with comprehensive major medical plans and standard underwriting departments – think Blue Cross and Blue Shield, United Healthcare, Aetna, and others like them – no indemnity policies with very low coverage limits) their underwriting guidelines will not have a large degree of variance from the norm. That being said, a pre-existing condition is defined in individual health insurance as any type of medical issue in the last 10 years.


Major Vs. Minor
Pre-Existing Conditions



Insurance companies will further segregate pre-existing conditions into 2 main categories: major and minor. Major pre-existing conditions will be things like heart disease, cancer, diabetes, etc. while minor pre-existing conditions will be things like high blood pressure, high cholesterol, mild asthma, etc.



Major pre-existing conditions will cause an individual health insurance application to be declined UNLESS the applicant is eligible for a federally mandated plan that is guaranteed issue – a HIPAA health insurance plan. With a HIPPA plan all pre-existing conditions will be covered and the insurance company cannot refuse coverage.



Minor pre-existing conditions can be handled one of two ways on the individual health insurance side depending on the health insurance company: rate up or rider. Rate up means that the insurance company will increase your monthly rate in order to cover all of your minor pre-existing conditions – this method is not as common as ridering. Ridering means that the insurance company will place a rider on the policy excluding coverage for the minor pre-existing conditions either for a set period of time (12 months, 24 months, etc.) or for an indefinite time period. The benefit to the ridering method as opposed to the rate up method is that the monthly premium does not increase."

http://www.healthquote360.com/Individual_Health_Insurance/Health_Insurance_for_Pre-Existing_Conditions.php