Health Insurance: Define pre-exisiting condition

percy212

This is the definition of pre existing condition as defined on hia.ie

"Pre-existing condition” means an ailment, illness or condition, where, on the basis of medical advice, the signs or symptoms of that ailment, illness or condition existed at any time in the period of 6 months ending on the day on which the person became insured under the contract."

I am puzzled about the six month period. Say for example:

1) I broke my leg many years ago, and as a result it is weak and prone to injury. Lets say its been fine for the six months before I sign up for health insurance but some time later it breaks again. Is this covered or not?

2) Say I had cancer ten years ago, but no evidence of it currently. Lets say it came back a year after signing up for health insurance. Would I be covered?

Thanks for any advice

okiss

Hi percy212

If your taking out a health insurance policy and you need to make a claim this is what happens.
Your claim is sent to the insurance company along with the insurance code for the operation/procidure you had done. All the insurance companies have a code for each type of operation or procidure ie 1244 - hip replacement done with x - as an example.

Medical staff in health insurance company review what you have done and can get medical records to confirm when your condition was likely to have started. You could have a medical condition that you were unaware off as you were not sick or in pain untill a period of time passed. Also something could have appeared in a blood test or xray that needed to be investigated. Some illness have a certain period of time before symptions appear.

If your doctor said to you that you need to have x operation done. You have no health insurance the day your doctor tells you this but you decide to buy health insurance then. You go to a private hospital and have x operation due. Your health insurance will not pay out in this case - as it was a pre existing condition & you knew you needed operation x.

If you have private health insurance and you are told you need to have operation x done. Ask the doctor for the procedure code for this with your health insurance company. Ring your health insurance company and give them this code along with the surgons name and hospital. They can confirm then if you should be covered for operation x.

Jim2007

All insurance contracts are known as 'contracts of the utmost good faith', that means you are required to disclose all information that might have a negative impact on the policy even if not asked. So this means that even if your circumstances does not meet the definition you may still find that the company refuses to pay out.

LostArt

percy212 wrote: »

This is the definition of pre existing condition as defined on hia.ie

"Pre-existing condition” means an ailment, illness or condition, where, on the basis of medical advice, the signs or symptoms of that ailment, illness or condition existed at any time in the period of 6 months ending on the day on which the person became insured under the contract."

I am puzzled about the six month period. Say for example:

1) I broke my leg many years ago, and as a result it is weak and prone to injury. Lets say its been fine for the six months before I sign up for health insurance but some time later it breaks again. Is this covered or not?

2) Say I had cancer ten years ago, but no evidence of it currently. Lets say it came back a year after signing up for health insurance. Would I be covered?

Thanks for any advice

1. Covered.
2. Yes, as long as you ave been in remission/clear for the 6 months prior to joining.

NUTLEY BOY

Do I read it correctly that the state of subjective knowledge of the policyholder proposing for health insurance is irrelevant to the issue of pre-existing condition ?

It seems that the verdict on whether or not a condition is pre-existing is that of the insurer on the supposedly objective view of the issue as per their medical advisers.

I understand that insurance contracts are regarded as uberrima fides but was wondering about the proposer who acts in genuine good faith in not declaring something the existence of which is unknown to him.

percy212

Thanks for the responses. Not trying to defraud you insurance shills. My question is genuine.

Aye Bosun

Sorry to tag on your post but very similar query.

I have a growth on my spine, had surgery in 2008 and again in Sept 2014 to remove it. I signed up for health insurance in May 2015. So an 8 month period between last surgery and signing up for health insurance. I've just found out that it's growing again and I will require either more surgery or some alternative treatment.

So does the 8 month gap between last surgery and signing up to insurance policy mean I will be covered under my insurance policy? I have also read about a 5 year waiting period before being allowed to claim on the insurance policy as it is a pre existing illness.

I'm totally at a lost as to where I stand.

Could anyone give me a bit of advice?

NUTLEY BOY

Just a view on the general issue.

If the new growth is definitely a recurrence of the previous problem it would look like it may well fall within the definition of a pre-existing condition.

However, whether it is a recurrence or not of a pre-existing condition seems to be a matter of medical judgment. Do not assume that it is actually a recurrence of the same condition as distinct from a new and separate occurrence of an identical problem.

If the original problem of 2008 was conclusively resolved that does not automatically mean that the 2014 and or the 2016 manifestations are repeats of precisely the same condition. They might be but that is a medical judgment.

An example might make the preceding point clearer. I break my arm in 2008 and it requires surgical repair. I make a full recovery but the same arm is broken again in 2016. Is that recurrence of a pre-existing condition or a separate and distinct matter ?

Look at this page of the Health Insurance Authority on the issue http://www.hia.ie/consumer-information/waiting-periods/new-customer-waiting-periods

I am not clear if you took out health insurance for the first time ever in May 2015 or if you signed up with a new provider then. If you have served the relevant waiting period with a previous health insurer(s) you may be alright.

You will see from the HIA site that, QUOTE, "From 1 May 2015 a pre-existing condition is defined as:

"Pre-existing condition” means an ailment, illness or condition, where, on the basis of medical advice, the signs or symptoms of that ailment, illness or condition existed at any time in the period of 6 months ending on the day on which the person became insured under the contract. UNQUOTE.

IMHO you probably need to get a technical medical view from your own doctor as to whether the condition is a recurrence of a pre-existing problem or a coincidental repetition of something similar. I can bet which way the insurers will argue it :rolleyes:

Aye Bosun

Thanks for your reply, I'm 99% sure it is a re-occurrence of the same growth as it has never been fully removed due to the proximity to my spinal cord and as you say I know what way the insurance company would go on that. So I'm assuming than that I must wait out the 5 year waiting period for pre-existing illness.

I only signed up for health insurance for the first time in May 2015 (I know I know, stupid as f*ck! but I was young when it happened the first time and never thought it would come back and was advised it wouldn't too)

So my next question is at the end of the 5 year wait time, If I then move insurance provider and upgrade my plan etc. am I subject to more waiting periods to be covered? or would it be better now to upgrade my plan even though it is of no use to me at all for another few years.

NUTLEY BOY

Aye Bosun wrote: »

Thanks for your reply, I'm 99% sure it is a re-occurrence of the same growth as it has never been fully removed due to the proximity to my spinal cord and as you say I know what way the insurance company would go on that. So I'm assuming than that I must wait out the 5 year waiting period for pre-existing illness.

I only signed up for health insurance for the first time in May 2015 (I know I know, stupid as f*ck! but I was young when it happened the first time and never thought it would come back and was advised it wouldn't too)

So my next question is at the end of the 5 year wait time, If I then move insurance provider and upgrade my plan etc. am I subject to more waiting periods to be covered? or would it be better now to upgrade my plan even though it is of no use to me at all for another few years.

AFAIK you need to serve a waiting period in respect of the upgraded element of cover. See this link to the HIA on the question http://www.hia.ie/consumer-information/switchingupgrade-waiting-periods

LostArt

When you are three years into your cover upgrade your plan, then the upgrade waiting period and initial pre existing waiting period will run concurrently for the last two years.

Aye Bosun

LostArt wrote: »

When you are three years into your cover upgrade your plan, then the upgrade waiting period and initial pre existing waiting period will run concurrently for the last two years.

Thanks for the info, so I'll upgrade the plan in May 2018 and then be fully covered by May 2020.
Just got keep the health issues at bay for another 3.5 years..no bother :rolleyes:

Thanks to all for the very helpful advice!