| Sources: | Data as of December 2008. Data compiled through review of state laws and regulations and interviews with state health insurance regulatory staff.
Data collection and analysis by researchers at the Health Policy Institute, Georgetown University. Special Data Request, February 2009. |
| Definitions: | In general, pre-existing conditions are medical conditions or other health problems that existed before the date of enrollment in an individual policy. However, the exact definition of pre-existing condition varies by state.
Some states use an objective standard allowing only those conditions for which someone actually received medical advice, diagnosis, care or treatment prior to enrollment to be counted as pre-existing. Most states use a broader, prudent person standard, which also includes conditions that were never diagnosed, but which exhibited symptoms for which an ordinary prudent person would have sought medical advice, care or treatment
In many states, health problems disclosed at the time of application may be permanently excluded from coverage by an amendment to the individual health insurance contract called an elimination rider. Once coverage begins, a consumer who makes claims under the policy may be investigated to see whether the health problem was pre-existing. In many states, it is not necessary for a health condition to have been diagnosed prior to the purchase of coverage for it to be considered pre-existing. Depending on state law, insurers can look back months or years prior to the policys purchase for evidence of a pre-existing condition. This process is sometimes called post-claims underwriting. In most states, the maximum pre-existing condition exclusion period constitutes a limit on post-claims underwriting. Any claim filed during the exclusion period can be investigated as possibly pre-existing and, if found to be so, can be denied and coverage for all further care for that condition can be excluded during the exclusion period. The maximum lookback period limits the period of history preceding purchase of a policy that can be investigated for evidence of a pre-existing condition. For example, in Alabama, an applicant for individual health insurance might have a known pre-existing condition permanently excluded from coverage. In addition, if she makes a claim for health care services during the first 24 months of coverage, her medical history dating back 5 years prior to the purchase of her policy can be investigated for evidence that her current health problem existed prior to the purchase of coverage. |
