What is a pre-existing condition, exactly?

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If you’re choosing a health insurance plan, you need to know how it will handle pre-existing conditions. The new health care reform law will prohibit insurers from denying coverage for pre-existing conditions in 2014, but until then the old rules stand for adults. (Children’s pre-existing conditions must be covered.)

A pre-existing condition is a health condition that was treated prior to the effective date of a new insurance policy. The term does not apply to a condition that the patient was not aware of and did not seek treatment for, according to Jackie Aube, vice president of product for the health insurer CIGNA.

Pre-existing conditions in group health insurance

In group health insurance plans (the type offered by employers), pre-existing conditions are covered as long as the patient had health insurance coverage for the 12 months prior to enrolling in a new plan, with no coverage gaps of 63 days or more, Aube says. If there was a coverage gap, then pre-existing condition exclusions can apply to your group health plan, according to the federal HIPAA law.

A group health plan may deny coverage for a pre-existing condition for a specified amount of time — usually 12 months. After that exclusion period is over, the condition will be covered.

To define “pre-existing,” insurers usually look back three to 12 months before the effective date of the policy. That’s called the “look-back period.” For example, if you were treated for eczema three years ago and haven’t sought treatment for it since then, it would not be considered a pre-existing condition.

Pre-existing conditions in individual health insurance

For those with individual health insurance, pre-existing conditions often are not covered, regardless of how long you had previous coverage or whether there was a coverage gap. Health insurance quotes can be very high for individual plans if you have a pre-existing condition.

Pre-existing condition insurance plans

In July, the U.S. Department of Health and Human Services announced Pre-existing Condition Insurance Plans, which covers adults who are unable to obtain individual health insurance due to a pre-existing condition. It’s a transitional program slated to end in 2014, when health insurance exchanges will take their place.

“For too long, Americans with pre-existing conditions have been locked out of our health insurance market,” says HHS Secretary Kathleen Sebelius. “This program will provide people the help they need as the nation transitions to a more competitive and fair market place in 2014.”

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