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Pre-Existing Conditions Exclusions: What You Need to Know

The Mayer, Graff & Wallace, LLP team explain pre-existing conditions exclusions and what to do when your claim has been wrongfully denied.

Pre-existing conditions exclusions were once common in health insurance plans, but thanks to new federal laws in the past decade, health insurance providers are generally no longer permitted to include these exclusions in their policies. For example, providers were able to deny applications, charge higher rates, or deny claims for persons with pre-existing conditions. While every policy is different, individuals who purchase health insurance through their employer or the national health insurance marketplace should no longer have to worry about these exclusions.

However, pre-existing conditions exclusions are still common with other types of health plans, most commonly “short term medical coverage plans.” These plans are not designed to act as long-term “health insurance,” and the terms and conditions of these plans reflect that. Routine procedures may not be covered or may be limited (such as costs for hospitalization) and there may be a maximum limit on total benefits payable. Consumers also usually pay more for these plans than they would for a traditional health insurance plan.

In particular, the pre-existing conditions exclusions in these plans can be harsh and often result in a difficult claims process. It is important to understand how these exclusions work. The plan will usually state that benefits will not be provided for a condition which a person was previously treated for until a certain period of time has passed. In some plans we have seen, the plan will look back as far as five (5) years and refuse to pay for treatment of any condition which a person was treated for in those 5 years. Other plans will also refuse treatment of conditions producing symptoms which would have caused a person to seek care or treatment. Then, the plan will usually require a person to wait 12 months after buying the policy before benefits are payable for treatment of pre-existing conditions, assuming the person is able to pay the premiums that long.

It is easy to see how these exclusions can be used by the plan provider to avoid paying claims. The first thing the plan provider will do is to engage in “post-claims underwriting.” The provider will require you to authorize them to look at all your medical records for the past several years. The provider will closely scrutinize your records and look for a way to connect your past medical treatment to your current claim. If there is a way to connect those treatments, then the provider will deny your claim.

After denying your claim, the plan provider will list every condition they think is a pre-existing condition, whether it is true or not. At this point, the provider hopes you will be discouraged and walk away. If you walk away, the provider does not have to pay any benefits and it gets to keep the premiums you already paid.

While it can be complicated to dispute these types of claims, it is not impossible. You should carefully look at your medical records and see if what the provider stated is true. For example, being treated for headaches does not mean you were treated for a brain tumor; being treated for stomach pain does not mean you were treated for stomach cancer. You should also carefully review your rights to appeal a denial and the timeline and process for appealing.


The MGW lawyers are experienced with disputing claims wrongfully denied because of pre-existing conditions exclusions. We can assist with writing appeals letters and, if necessary, filing a lawsuit against the plan provider to get the benefits you paid for. Contact us today for a free consultation.

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