How Pre-Existing Conditions Affect Your Insurance Policy Claim

Posted by Richard P. Hastings | Sep 16, 2021 | 0 Comments

Pre Existing Condition

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:

  • Cancer
  • Chronic illnesses, such as diabetes
  • Arthritis
  • 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.

Objective Standard

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.

Prudent Person

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.

Asymptomatic Conditions

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.

If you have any further questions, click here to contact us or call our office at (203) 438-7450.

About the Author

Richard P. Hastings

Attorney Hastings concentrates his practice on personal injury and litigation. Devoted to helping those who have suffered some type of wrong, Richard P. Hastings concentrates his law practice on personal injury law.


There are no comments for this post. Be the first and Add your Comment below.

Leave a Comment


Aenean lacinia bibendum nulla sed consectetur. Donec sed odio dui. Maecenas sed diam eget risus varius blandit sit amet non magna. Nulla vitae elit libero, a pharetra augue. Curabitur blandit tempus porttitor. Morbi leo risus, porta ac consectetur ac, vestibulum at eros. Cras justo odio, dapibus ac facilisis in, egestas.

Let Us Fight for You

Local Presence. Statewide Coverage.

When you choose Hastings, Cohan & Walsh, LLP you will receive the one-on-one attention and individualized support that you deserve. Our Connecticut personal injury attorneys will not treat you as just another case number nor will we hand your case off to a paralegal.

Unlike other law firms, we will personally handle each legal aspect of your case, walking with you every step of the way. We aim to provide the highest quality representation possible. We have extensive experience and training in a variety of aspects of personal injury law. We obtain the knowledge and skill-set necessary to maximize your compensation.

Ridgefield Office
Mon: 08:30am - 05:00pm
Tue: 08:30am - 05:00pm
Wed: 08:30am - 05:00pm
Thu: 08:30am - 05:00pm
Fri: 08:30am - 05:00pm