Preexisting condition: Definition, insurance options, and more

A preexisting condition refers to a health condition that a person had before the date their new health coverage starts. Insurers cannot usually charge more or deny coverage to someone with a preexisting condition.

This article explores how United States insurers classify preexisting conditions, when they can deny or cancel coverage, and insurance options for people with preexisting conditions. It also discusses how to appeal health plan decisions.

Preexisting conditions encompass any health conditions a person had before applying for or enrolling in a new health insurance policy.

Health insurers define what preexisting conditions are, so the exact definitions may vary depending on which insurer a person chooses. However, some examples of preexisting conditions include:

Health insurance companies require people to declare any preexisting conditions they have during the application and enrollment process.

The Centers for Medicare & Medicaid Services (CMS) notes that around 82 million Americans with employer-based health coverage have a preexisting condition.

Since the introduction of the Affordable Care Act (ACA) in March 2010, health insurance companies generally cannot refuse someone coverage or charge them more due to a preexisting condition.

However, if a person has a grandfathered health plan, their insurer does not have to cover preexisting conditions.

Grandfathered health plans refer to individual health insurance policies that a person or their employer purchased on or before March 23, 2010. Insurance companies, brokers, and agents sold these plans. They were not available through the Marketplace.

People can switch from a grandfathered health plan to a Marketplace plan during the yearly open enrollment period, which runs from November 1 to January 15. Coverage can start from January 1, but a person needs to contact their insurer to learn about how and when to cancel their current plan.

If the grandfathered plan year ends or the insurer cancels it, people can switch during a special enrollment period. Special enrollment periods run from 60 days before until 60 days after the grandfathered plan ends.

If someone is unsure about how open enrollment and special enrollment periods work, they can contact their health insurance company for further information and support.

Health insurance companies can cancel a person’s coverage if they intentionally put false or incomplete information on their insurance application, such as not disclosing a preexisting condition, or if they do not pay their premiums on time.

However, health insurers notify people at least 30 days before they cancel their coverage, during which time they may appeal the decision or find new coverage.

Additionally, health insurers cannot cancel a person’s coverage if they or their employer made a mistake on the insurance application. This includes grandfathered health plans.

If a health insurance company refuses to pay a claim or decides to end coverage, a person has the right to appeal the decision and request a third party to review it.

People can ask their insurer to reconsider the decision by internal appeal or external review.

Internal appeal involves asking the health insurer to conduct a full and fair review of its decision. In urgent cases, health insurers must speed up this process.

External review involves taking the appeal to an independent third party. In these scenarios, the health insurance company does not have the final say over whether to pay a claim.

Preexisting conditions include any health conditions that a person had before applying for or enrolling in a new health insurance policy.

The Affordable Care Act (ACA) ensures that insurers usually cannot charge more or deny coverage to someone with a preexisting condition. However, the ACA does not apply to grandfathered health plans.

If an insurer denies or cancels a person’s cover, they have the right to make an internal appeal or an external review.