Pre-existing conditions

Pre-existing conditions are medical conditions or health issues that existed in a person before his insurance policy comes into effect. The insured person may know these conditions or not. It is quite possible that these may be diagnosed or not or may be untreated too. To name a few of these conditions:

• Arthritis
• Asthma
• High blood pressure
• Heart disease
• Cholesterol
• Alzheimer
• Epilepsy
• Acne
• Diabetes
• Cancer
• Kidney ailments
• Pain in the back/knee

Acute onset of pre-existing conditions

The term “Acute Onset of a Pre-Existing Condition(s)” shall mean a sudden and unexpected outbreak or recurrence of a Pre-existing Condition(s) which occurs spontaneously and without advance warning in the form of Physician recommendations or symptoms, is of short duration, is rapidly progressive, and requires urgent care. The Acute Onset of a Pre-existing Condition(s) must occur after the effective date of the policy. Treatment must be obtained within 24 hours of the sudden and unexpected outbreak or recurrence. A Pre-existing Condition that is a chronic or congenital condition or that gradually becomes worse over time will not be considered Acute Onset.

A few visitor insurance plans offer coverage for acute onset of pre-existing conditions upto certain extent. In case of claim processing, only a medical authority/expert would be able to qualify if a medical condition is pre-existing condition or not. Past and present medical history of the insured will be taken into account to establish if the condition is pre-existing. Also, it should be noted that the insured person is responsible to keep the pre-existing condition at bay i.e. under control.

Determining acute onset of pre-existing condition or pre-existing condition

For processing of claims related to the acute onset of pre-existing conditions, following determines whether a condition was preexisting or not:

1. Health history: When a patient sees a doctor, they require filling a health history form listing their current and past health records. This helps in determining about the general health of the insured person.

2. Doctor’s reports and diagnosis: Based on doctor’s reports, consultation and results of prescribed laboratory tests, doctor gets a clear assessment of insured’s current health status.

After the tests and consultation with the insured (the patient), the doctor sends his diagnosis and results to the insurance company. Before this, neither the insured person, or the insurance agent/doctor/insurance company is aware of the outcome whether the medical problem that occurred was due to a pre-existing condition or not. The claim department reviews the claim of the insured based on these reports. Sometimes, if needed the insurance company’s claim representative makes necessary phone calls, collects his own data to get detailed insight into the claim. Based on all this, the insurance company finds out, if it was acute onset of pre-existing condition or pre-existing condition. It should be noted and remembered, some insurance plans do cover acute onset of pre-existing conditions but all insurance insurance plans exclude pre-existing condition.

What conditions are generally excluded from coverage?

• Routine prenatal care, Pregnancy, childbirth, and postnatal care.

• False labor, edema, prolonged labor, prescribed rest during the period of Pregnancy, morning sickness and conditions of comparable severity associated with management of a difficult Pregnancy.

• Diagnosis or treatment related to birth defects and congenital illnesses. Birth defects are deemed to include hereditary conditions.

• Charges for the diagnosis or treatment of Mental Health Disorders

• Modifications of the physical body intended to improve the psychological, mental or emotional well-being of the Member, including but not limited to sex-change Surgery.

• Willful and/or therapeutic termination of Pregnancy except in connection with covered Complications of Pregnancy.

• Dental Treatment, except for Emergency Dental Treatment necessary to replace sound natural teeth lost or damaged in an Accident covered hereunder or for the Emergency relief of Acute Onset of Pain.

• Corrective devices and medical appliances, including eyeglasses, contact lenses, hearing aids, hearing implants, eye refraction, visual therapy, and any examination or fitting related to these devices, dentures or dental appliances, and all vision and hearing tests and examinations.

• Dental Treatment, except for Emergency Dental Treatment necessary to replace sound natural teeth lost or damaged in an Accident covered hereunder or for the Emergency relief of Acute Onset of Pain.

• Corrective devices and medical appliances, including eyeglasses, contact lenses, hearing aids, hearing implants, eye refraction, visual therapy, and any examination or fitting related to these devices, dentures or dental appliances, and all vision and hearing tests and examinations.

• Medical expenses for Injury or Illness resulting from extreme sports such as :

• • mountaineering at elevations of 7,000 meters or higher;
  • aviation (except when traveling solely as a passenger in a commercial aircraft);
  • base jumping, parachuting, parasailing hang-gliding; sky surfing;
  • off-road motorized vehicles including all-terrain vehicles, snowmobiles and motorized dirt bikes, and tractors;
  • heli-skiing, snow skiing, or snowboarding,
  • white water rafting;
  • racing by any animal, motorized vehicle, or BMX;
  • spelunking or cave diving;
  • sub aqua pursuits involving underwater breathing apparatus
  • avalanche training;
  • Aussie rules football;
  • big game hunting, running with the bulls;
  • bobsleigh, skeleton or luge;
  • any type of boxing or martial arts;
  • hot air ballooning as a pilot;
  • modern pentathlon;
  • powerlifting;
  • quad biking outdoor endurance events.

When in doubt, contact your insurance agent to understand what is covered and what is excluded when it comes to acute onset of pre-existing conditions. Some plans offer limited coverage for the acute onset if the insured person is under age 65 years and some offers for under age 70 years. Call us today to get quotes or visit our website to compare plans that offer acute onset of pre-existing conditions coverage.

Category: Visitor Insurance

July 03, 2015 at 06:39 AM