Why you can trust Insure.com

insure logo
quality icon

Quality Verified

At Insure.com, we are committed to providing honest and reliable information so that you can make the best financial decisions for you and your family. All of our content is written and reviewed by industry professionals and insurance experts. We maintain strict editorial independence from insurance companies to maintain our editorial integrity, so our recommendations are unbiased and are based on a comprehensive list of criteria.

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.”

Go To Top