More on Pre-Existing Conditions

Winter 1999 CSANews Issue 34  |  Posted date : Mar 04, 2007.Back to list

We now realize that medical questions are asked on an insurance application to determine your eligibility for a policy and the price you must pay. They have nothing to do with the pre-existing condition clause.

We also know that a short pre-existing condition period, during which your health condition must be stable, is preferable to a long time period. If you are unable to meet this pre-existing condition (say, 90 days) of stability, then you must delay your trip until the 90 days are past; otherwise, a claim for your health problem or anything related to your health problem will be denied.

The next pre-existing condition, found in most policies for longer trips and older ages, is the hospital pre-ex. This condition says that if you have been hospitalized, then you have no coverage for that health problem or any claim related to it. The simplest, and most dangerous hospital pre-ex, is the one that simply states that, if you attended at a hospital, you are not covered. This would include an emergency room visit at any time in your entire life, for any reason. A chest pain twenty years ago, trouble breathing during a smog alert, a viral infection what claims could be denied based on any of these incidents?

The hospital pre-ex is, once again, usually in your favour if it is more complicated. For instance, if the words 'admitted to hospital' are in the clause, most minor emergency room visits will now NOT be considered in reviewing your claim, and the claim will probably be paid.

There are, however, many situations in which you are actually 'admitted to hospital,' and you don't realize that this has happened. It depends on the actual hospital and their procedures. You may find that you were 'admitted' but you were only there for three or four hours. The second thing you should look for, in order to avoid this, is a length of admittance clause i.e. admitted for 24 hours or 48 hours or 72 hours. Needless to say, the longer the length of admittance requirement, the better for you. If the hospital pre-ex states 'admitted to hospital for more than 72 hours,' a hospital stay of less than that does not count against you. Some policies may have hospital clauses which only penalize you if you have been admitted twice for the same condition. These are rare, and they normally don't have the advantage of a required length of admittance.

In the same way that the basic stability pre-ex has a time period (i.e. 90 days), a hospital pre-ex may have a time period. Again, the shorter the time period, the better for you. The Medipac policy only looks at hospital admittances in the past one year. Some policies may be two years, five years or 10 years. If no time period is mentioned, then it is a lifetime hospital pre-ex, the worst possible condition.

The hospital pre-ex is one that requires some judgement on your part. If you were hospitalized with a broken leg last year, and it has healed, there is probably no need for concern. If the same broken leg has steel rods and pins in it and you have had trouble with infection, I would not travel. Look at the reason for your hospitalization, is it likely to happen again? Can there be complications? Review the length of admittance requirement and the time period involved and make your own decision.

The last thought on pre-existing conditions relates to what I call 'claims underwriting.? There are usually few, if any, medical questions on the application and it all seems so simple and easy, so you buy the policy. But at the time of your claim, the insurer now decides whether you have coverage, or not. Tucked away in the pre-existing clause is the 'lifetime' pre-exist. If you ever had a health problem or anything related to your claim, you're not insured. Another variation on this is the 'referral to specialist' clause. If you were ever referred to a specialist, you are not insured for that condition or anything related to that condition. Those companies don't ask what the results of your specialist visit were, they just decline your claim. Claims underwriting is, I believe, unfair to the policy-holder. On the surface, it gives the expectation that your claim will be paid, but the simple pre-ex clause wordings exclude almost anything for which you have ever seen a doctor.

Read the policy; understand the policy; pay special attention to the pre-ex clauses, the exclusions and the general conditions, and then you can buy your policy with confidence that any claim you may have will be paid.