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Limitations On Pre-Existing Health Condition Exclusions/Waiting Periods

The Look Back Period

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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).

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