What is a Pre-Existing Condition?
The term “pre-existing condition” can be confusing in many ways when used in insurance policies and when submitting claims for personal injury or medical malpractice cases.
A pre-existing condition is a medical condition that you had before you signed the insurance policy, were involved in an injury case, or were injured through the fault of a hospital, doctor, or other health care professional. Examples of pre-existing conditions are:
- Chronic illnesses, such as diabetes
- Prior injuries to the same body part, such as neck injuries, back injuries, brain injuries, and broken bones
- Mental health issues
Most medical conditions and issues can be considered as pre-existing conditions.
The Two Categories
Insurance companies define pre-existing conditions in one of two categories: the “objective standard” category or the “prudent person” category.
The “objective standard” classification means any medical condition for which you visited a health care provider or received treatment for a specified period of time (i.e. 6 months) before you enrolled in the insurance plan.
The “prudent person” classification is when you have symptoms for which a prudent person would have sought treatment, regardless of whether you did or not.
The Insurance Company
The insurance company should make it clear in the policy which category of “pre-existing condition” it follows and provide you with a list of medical conditions which it considers pre-existing conditions.
If the term “pre-existing conditions” sounds somewhat vague and advantageous for the insurance companies, it can potentially become even more biased in the insurer's favor if you have the misfortune to become injured or ill.
Even if you do have a pre-existing condition and disclosed it to your insurance company when you applied for an insurance policy, this does not mean you are automatically disqualified from insurance benefits if your condition becomes worse because of injury. While it is often the strategy of the insurer, or its attorneys, to deny your claim, there is a legal basis for you to collect payment. Even when a person has a pre-existing condition, The United States Supreme Court has ruled that if an injury or accident aggravates that condition and makes it worse, the person(s) responsible for the injury or accident are liable.
Another murky area of pre-existing conditions that insurers (or their attorneys) make use of is when a person's pre-existing condition is asymptomatic (he or she has no symptoms) and an accident causes symptoms to flare up. While the insurer may attempt to refuse payment because a pre-existing condition existed, courts in the United States have ruled Defendants are liable to the injured person for triggering symptoms or aggravating the asymptomatic pre-existing condition.
In the case of illness, your insurer might take the position that your illness is caused by or related to a pre-existing condition. For instance, if a person has a history of depression and then develops fibromyalgia syndrome, a complex disorder of muscle and connective tissue pain, the insurer might attribute the fibromyalgia to that person's pre-existing mental disorder. Meanwhile, fibromyalgia can also be caused by trauma as a result of an accident or injury.
Dependent on the circumstances, the insurance company may be liable for payment of a portion or all of the policy's monetary obligations.
Injured with a Pre-Existing Condition?
If you have become ill or injured and the insurance company is denying your claim based on a pre-existing condition, you should contact an attorney experienced with the principles of pre-existing conditions immediately to review your case and provide legal assistance in settling your claim justly with the insurance company.