Pre-Existing Medical Conditions


For many travelers this may be the most important travel insurance subject and at the same time the most confusing. The confusion starts with the fact that everyone probably thinks they know what a pre-existing condition is and they're almost certainly wrong.

What is a "pre-existing medical condition?" Unfortunately, no one can give a simple, consistent answer to that question. It would be nice if the travel insurance industry had a set definition that all of the insurers used but they don't. Instead, you can do your homework and learn how insurer A defines a "pre-existing medical condition" and when you take a look at insurer B you have to forget everything you just learned, re-learn the information for the new plan, and try not to get the two confused.

The only thing that ALL travel insurers agree on regarding losses due to pre-existing medical conditions is that they are excluded. Note that some insurers (not all) will waive this exclusion if the traveler meets certain requirements. We'll cover these waivers here.

Let's start by taking a look at the definition of a "pre-existing medical condition" from one major insurer:

"Pre-Existing Condition : means an illness, disease, or other condition during the 60 day period immediately prior to the Effective Date for which You or Your Traveling Companion:

1) exhibited symptoms which would have caused one to seek care or treatment; or

2) received or received a recommendation for a test, examination, or medical treatment or

3) took or received a prescription for drugs or medicine.

Item (3) of this definition does not apply to a condition which is treated or controlled solely through the taking of prescription drugs or medicine and remains treated or controlled without any adjustment or change in the required prescription throughout the 60 day period before the Effective Date. "


Let's break this down and take it a little bit at a tinme:

"Pre-Existing Condition : means an illness, disease, or other condition during the 60 day period immediately prior to the Effective Date for which You or Your Traveling Companion . . . "

Let's stop right there. Already we have two very important topics that need to be understood. #1 is "Effective Date". Go here for a discussion of that term. If you don't completely understand "Effective Date" nothing else will make sense. Short version: your cancellation coverage becomes "effective" almost immediately. With most plans, if you pay for your policy today it becomes effective at midnight tonight. There are exceptions so please read the long version.

You'll often hear/read about a plan's "look back period" although you'll probably never actually find that term in the plan's documents. Basically the "look back period" is the time frame that a insurer can go back into your medical history to determine whether or not a medical condition is "pre-existing". What date are they looking back from? In the case of a cancellation claim with this plan it's the 60 day period prior to the "Effective Date".  Remember -- buy today, effective at midnight tonight for the cancellation coverage. Note: other plans will look back 180 days, a year, or even longer. Be sure to check each plan.

Let's say you buy a policy on June 6th and becomes effective at midnight that night. Then on October 3rd you have to cancel your trip for a medical reason. To determine if this medical situation is "pre-existing" or nothe insurer will only "look back" at your medical history from June 6th and back 60 days from there. Anything new that pops up after the "effective date" of the coverage (remember -- for cancellation coverage that would be "buy today, effective at midnight tonight) cannot be a pre-existing condition and anything that happened prior to the look back period cannot be a pre-existing condition. Let's call the "look back period" in this case April 6th through June 6th.

Perhaps had pneumonia a year before buying the policy and during that April 6th through June 6th "look back" period there are no symptoms, no treatment, no nothing. A week before your trip begins you get another case of the same thing. In this case your claim would be paid because your doctor will give you a clean bill of health for the pneumonia for that 60 day "look back period" of April 6th through June 6th. But if you were unfortunate enough to buy a plan with a 24 month "look back period" you'd be out of luck as it would encompass the original bout of pneumonia and the claim would probably be denied. In general, the shorter the look back period the more consumer-friendly the policy is in this regard.

#2 tells us to whom the definition/exclusion applies.

Say you're most worried about the medical situation of a family member who is not traveling with you, perhaps an elderly parent or in-law. And let's say that person has a chronic condition that he's been dealing with for years. Suddenly, right before you leave on your trip, he passes away due to that condition and you have to cancel. Would your claim be denied because that relative died of a pre-existing condition? No. The pre-existing condition definition/exclusion for this plan only applies to losses that occur if it's the insured traveler or a traveling companion that has the medical condition causing the cancellation.

To compare, here's how another plan defines to whom the definition/exclusion applies:

"You, a traveling companion or family member are considered to have an existing medical condition  . . ."

 
OK. Then when you check the plan's definition of "Family Member" you find:

"Any of the following people, whether or not they're traveling with you:

* spouses and common-law, civil union and domestic partners
* parents and step-parents
* children and step-children (including adopted . . . "


So with this second plan, in that same example scenario, the claim would probably be denied because that relative DOES fall under the plan's definition/exclusion of a pre-existing condition because it does apply to non-traveling family members..

Now let's go back at the second part of the definition of the first plan we were looking at:

"1) exhibited symptoms which would have caused one to seek care or treatment; or 2) received or received a recommendation for a test, examination, or medical treatment or 3) took or received a prescription for drugs or medicine. "


 The insurers can leave themselves a lot of wiggle room with 1). Just ignoring a medical problem or delaying seeing a doctor until after you've purchased your policy may not be enough to get around the pre-existing medical condition exclusion. The rest is pretty straightforward.

The last section of the definition is a biggie:

"Item (3) of this definition does not apply to a condition which is treated or controlled solely through the taking of prescription drugs or medicine and remains treated or controlled without any adjustment or change in the required prescription throughout the 60 day period before the Effective Date."


First off, please be sure you understand the term "effective date".

I'm a diabetic and have been for 15 years. I take my meds every day, get regular checkups, and nothing has changed -- the diagnosis, treatment, prescriptions, and prognosis -- in a few years. If I cancel my trip because the diabetes flares up will my claim be denied? Let's find out with the above example:

Did my condition/illness exist in the 60 day period prior to the effective date of the policy?   Yes, because according to 3) I "took or received a prescription for drugs or medicine" So, by this section of the definition my diabetes is a pre-existing condition.

But where do I stand with respect to the following: "Item (3) of this definition does not apply to a condition which is treated or controlled solely through the taking of prescription drugs or medicine and remains treated or controlled without any adjustment or change in the required prescription throughout the 60 day period before the Effective Date."

In the 60 day period prior to the cancellation coverage's "effective date" was my condition controlled solely through the taking of prescription medication? Yes. I did not receice any other treatment such as dialysis or some kind of surgery.

In the 60 day period prior to the plan's cancellation coverage "effective date" was there any ANY change in my prescription? No.

So according to this plan my diabetes does NOT fall under their definition of a pre-existing medical condition and if, after purchasing a policy, I have to cancel or interrupt my trip because my illness flares up I would be covered.

The insurers are willing to take a reasonable chance that someone like me who is planning a trip and who has a stable medical condition won't have to cancel. They pay a few more claims but the vast majority of these travelers go on their trip exactly as planned. They've crunched the numbers and figured out that they make more money by not applying the pre-existing condition exclusion to these people who are "medically stable" instead of losing their business to some other company.

One thing to keep in mind -- when they say "without any adjustment or change" that's exactly what they mean. Perhaps you've had your med's dosage reduced 30 days before buying the policy. A sign your condition is improving, right? Maybe. But the insurers are worried that perhaps the doctor will get the new dosage wrong and the condition will flare up again.

Why is this important? There are many plans out there that do not offer a waiver of the pre-existing condition exclusion. And also quite often travelers will delay purchasing a policy until after they are past the timeframe when the waiver is available. Only by reading and understanding the plan's pre-existing condition definition can they figure out if their medical situation, either concerning themselves or a non-traveling family member, can be covered.

But again, you cannot take your new understanding of this plan's definition of a pre-existing condition and assume it's the same for any subsequent plans you look at. You have to do this for every plan, even plans from the same insurer, every time. If you don't you could be making a very expensive error.

In the last decade or so many insurers have made available a "waiver" of their normal pre-existing condition exclusion if the traveler meets certain requirements. Read here for more on this topic.

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