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Pre-Existing Medical Conditions

March 13th, 2009 – Our clients often ask what types of injuries or illnesses would be considered a pre-existing medical condition under our carriers’ individual health insurance plans.    The answer is that when you apply for an individual health insurance plan you will be asked to disclose anything that you have been treated for during the review period which typically ranges from 5-10 years.

While that may seem daunting not all pre-existing conditions are cause for concern.   While a child’s visit to a doctor for an ear infection a year ago, with full recovery and no treatment since will not usually result in any underwriting action; repeated treatment for reoccurring ear infections for that child very well may be an issue.  This is also true for combinations of certain injuries or illnesses. A diagnosis of a condition by itself may not pose a significant issue, but a diagnosis of the same condition in conjunction another health condition (smoking and excessive weight often come into play) may complicate matters significantly.

In Colorado, whether that prior treatment will be problematic to getting an individual health insurance application approved depends on:

  • The diagnosis for injury or illness
  • The severity of that condition
  • How long ago it occurred
  • If the condition is resolved or unresolved and
  • Whether it has reoccurred over time

We are often asked how an insurance company will respond to health conditions when they underwrite a individual health insurance policy. That too, depends on the health condition as well as the company and their particular underwriting guidelines.  Once an individual health insurance application is underwritten, a health insurer may:

  • Accept the application
  • Accept the application, but exclude (rider) a pre-existing condition*
  • Accept the application, but with an increased premium applied (surcharge) and fully cover the pre-existing condition*
  • Decline the application

Note: Exclusionary riders may be permanent or for a pre-determined period of time, which may be reviewable in the future.  Ratings or premium surcharges are also sometimes reviewable in the future.

But what if I have continuous coverage?  Having continuous coverage or coverage with a lapse period of no more than 63 days may allow you to waive the blanket pre-existing waiting period.  The pre-existing waiting period is principally designed to protect insurance companies from claims by people that were previously uninsured. People without continuous coverage or that have allowed their creditable health insurance coverage to lapse more than 63 days may be subject to a pre-existing condition waiting period up to a maximum of 12 months for individual plans in Colorado.

That means that for up to 12 months the insurance carrier does not have to cover people for things they were treated for during the 12 month’s prior to their new policy’s effective date.   While continuous coverage or a lapse of under 63 days will helps people avoid the blanket pre-existing waiting period of up to 12 months, their individual health insurance plans are still fully medically underwritten and the insurer can still approve, exclude conditions, charge a higher than standard premium or decline the application.

Since these actions for many pre-existing conditions vary by insurer you will can save a huge amount of time and energy by discussing pre-existing conditions with a knowledgeablehealth insurance broker with expertise in working with a variety of Colorado’s individual health insurance carriers.   A health condition that may be declined by Company A could very well be approved by Company B.

A good health insurance broker will know the likely underwriting response for many health conditions and will help guide you in the right direction, so you are applying for coverage with the insurance company most likely to give you a favorable outcome.   Brokers will sometimes do “underwriting pre-screen” requests if there is an unusual health condition or a combination of health conditions to further increase your odds of success.

If a person has a health condition that makes them uninsurable, a good broker will also explain their options to them as well.   There are solutions for most situations if you work with an knowledgeable broker who has sufficient expertise to help you find the best option.

Please be sure to forward this article to a friend in need.   Feel free to comment on this article below.

{ 4 comments… add one }
  • Mike Hughes July 26, 2010, 7:07 am

    I am moving to CO next month. Am 40 pounds over weight. Have been treated for stricture in the urinary tract. I have to insert a cathater daily to keep the tract open. I’ve been untreated for 2 years since a surgery took care of the problem. I’m on medication for high blood pressure. I’m 36. Can I get health insurance?

    • Mark July 26, 2010, 9:03 am

      Hi Mike, the stricture may prove to be problematic to getting a new individual health insurance plan in Colorado. And, to get onto our high risk pool here (CoverColorado) you must be a Colorado resident for at least 6 months. So, get a Colorado Drivers license right away when you move here to help establsh your residency and see how long you can keep your current coverage. Some individual carriers may allow you to “Port” an existing individual policy over to Colorado. If you’re on a group plan and quitting that job, then elect COBRA or Continuation Coverage and be sure you don’t miss a COBRA payment so your coverage doesn’t lapse until you can get approved for a new policy from CoverColorado OR get onto an employer sponsored group plan here in Colorado. You don’t have to worry about pre-existing conditions if you can get onto an employer sponsored group plan here in Colorado. Hope that’s helpful Mike!

  • Linda November 30, 2010, 7:40 am

    I am hoping to purchase an individual policy soon. I have not been treated for any pre-existing conditions. However, during a recent emergency room visit I measured a high blood pressure reading and was urged to visit my primary care doctor to get it checked out. I have not been to the doctor but I have been monitoring my blood pressure and it is consistantly high. Even though I have not been diagnosed and/or treated for high blood pressure, if I have symptoms of a pre-existing condition, will I be denied health coverage in Colorado?

    • Mark November 30, 2010, 8:32 am

      First off, high blood pressure is very risky and you should go to the doctor immediately, regardless of insurance. High blood pressure puts you at higher risk for stroke or possibly having a heart attack. The good news is that high blood pressure medication is typically very inexpensive, so you should follow the medical advice given to you and go to the doctor ASAP.
      Your good health should be for your first concern, although your worries about pre-existing conditions do have some merit. Since you had high blood pressure at an emergency room and were urged to see a doctor for it you would need to disclose that on a health insurance application, which very well may result in your application being denied. Because the risk of stroke is so significant for high blood pressure, many insurance companies want to see you have 6 months of well controlled blood pressure before you’ll be approved. However, if you are denied then you may become eligible for CoverColorado, our non-profit safety net insurance program.

      Bottom line, go to the doctor and take care of yourself first please!

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