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A Pre-Existing Conditions Provision in a health insurance plan excludes coverage for health care due to a condition which exists at the time the policy is issued. The exclusion (also known as a "waiting period") continues for a described period of time that starts running when the policy is issued.

It is very common for a health insurance policy to exclude coverage for existing health conditions during a "pre-existing condition waiting period." If this kind of period applies to you, there will not be any coverage for your existing health condition until the period expires.

There are two time periods to be noted:

  • The look back period which is used to identify pre-existing health conditions, and
  • The waiting period.

Both of these periods are limited by The Health Insurance Portability and Accountability Act of 1996, generally referred to as "HIPAA". As you read the other sections of this article,keep in mind that HIPAA applies to all employers with 2 or more employees.

If you are starting group coverage with an employer and you have had other health insurance coverage recently, you may avoid a new Pre-Existing Condition Waiting Period because of the time you spent under prior insurance thanks to HIPAA.

For more information, see:

NOTE: Because of the Affordable Care Act (*Obamacare"), pre-existing condition exclusions are no longer permitted.       

The Look Back Period

Health insurance policies have a variety of definitions of a pre-existing condition including the length of the period to be looked at, and how it is determined whether a condition existed during that period. HIPPA establishes a uniform definition for coverages which are subject to HIPAA.

Under HIPAA, a health condition is only pre-existing if:

  • During a maximum of the 6 month period ending on the enrollment in the group plan.
  • There is a physical or mental condition>For which medical advice, diagnosis, care or treatment was recommended or received.
  • For which medical advice, diagnosis, care or treatment was recommended or received.

If all these events occur together, then that condition is considered a "pre-existing condition" and the new health insurance plan can impose a waiting period for coverage of the health condition. (Even though there may be a waiting period about this condition, that does not affect coverage of any other health conditions that existed before the look back period, or that start after enrollment in the plan.)

A few examples help illustrate:

Example 1. Kate has diabetes and regularly takes insulin. She became insured at an employer on July 1, 2010. She will be covered for any illness or accident except diabetes until the Waiting Period that postpones coverage for pre-existing conditions is over. Diabetes is a Pre-Existing Condition because she had treatment for it in the six months ending.

Example 2: Tom also became covered on July 1, 2010. Tom had cancer surgery two years ago and has been monitored ever since. His last doctor's visit was in November, 2009. Cancer is NOT a Pre-Existing Condition for Tom because he did not have treatment in the six months before his coverage started (January 1, 2010 TO July 1, 2010).

The Waiting Period

Once the Look Back Period determines which conditions are Pre-Existing, the Waiting Period is the period of time you must wait to have coverage for the Pre-Existing Condition. Under HIPAA, the Waiting Period cannot exceed twelve months (365 days) if you sign up for the health coverage as soon as you are permitted to by the employer.

Two examples:

Example 1. Kate, the person in Example 1 in The Look Back Period section above, will have coverage for diabetes on July 1, 2011 twelve months after her effective date of coverage.

Example 2. Tom, the person in Example 2 above: If Tom is found to have cancer in August, 2010, he will have coverage for it since cancer is not a Pre-Existing Condition according to the contract.

A Longer Waiting Period For Late Enrollees

If you do not sign up for health coverage as soon as permitted, you are considered to be a "Late Enrollee." The waiting period for late enrollees may be as long as 18 months.

There is an exception. HMOs that do not use a pre-existing exclusion may impose an affiliation period of 60 days. This is a waiting period in addition to the employer's Probation Period, during which there is no coverage and no premiums can be charged.

How Can I Learn Whether An Employer's Plan Has A Pre-Existing Condition Waiting Period?

If you are considering going to work for an employer and would like to know about whether there is a pre-existing condition provision in the health plan, and, if so, the terms, check the employer's web site. If there is no information there, you can either ask at an interview or after you get a job offer and before you accept it. You can preface your request with a statement such as "My pushy brother-in-law has been doing financial planning for me and insists on knowing about the benefits at my job. Would you mind telling me about the ins and outs of benefits such as health insurance, disability insurance and retirement plans, what's covered, when coverage starts, that sort of thing...."

If you are already working for a new employer, to find out what if any limitations are contained in the health insurance plan, read your Summary Plan Description. If there is a Pre-Existing Conditions Provision and Waiting Period, it will be spelled out. It is usually a separate provision with a bold heading.

If there is no provision about Pre-Existing Conditions, then there is no waiting period. Look carefully to make sure it's really not there, not that you just overlooked it the first time through.

If There Is A Pre-Existing Condition Exclusion, Does It Mean I Can't File Claims?

If your plan has a Pre-Existing Conditions Waiting Period and you have what HIPAA defines as a pre-existing condition, (see Pre-Existing Conditions above), it is possible that claims for that condition will not be covered during the waiting period. But that doesn't mean you shouldn't file the claim anyway.

Unless you haven't told your employer about your health condition and don't want to for some reason, you should file the claim if there is even the slightest possibility that the claim will be covered because it is not directly related to the pre-existing condition.

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