"Preexisting Medical Condition" -- As Of When? How Do They Find Out?

I haven’t read the Obamacare tome (why should I? Congress didn’t). But I gather it limits exclusions on preexisting condition.

But – how do they find out in the first place? What makes it officially preexisting? I ask because I know that under HIPAA (?), medical records are super-confidential in a lot of cases. And it’s not like there’s a centralized database (is there?) of my endocrinologist in Fresno’s notes with my those of my internist in Minneapolis or syphillologist in Tijuana such that they could piece together that as of date X I had incipient type II diabetes with chlamydic complications.

Or do they use insurance billing/claims records (which I guess may be centralized?). If that’s the trigger event, I guess if I was in Tijuana paying cash, as a practical matter it’s not pre-existing.

Finally, to return to my diabetes example (or emphysema, or any slow-onset/chronic condition) – when do I go from being a fat insulin resistant twinkie guzzler to a “type II diabetic” for something to be “preexisting” as of date X? Is it a magical DX code appearing in the insurance records, or more subjective (under the current regime, that is, where preexisting condition coverage can be excluded)?

When you apply, you will be asked to allow access to your past history and if you are currently being treated for any conditions.

You generally need to fill out an EoI (Evidence of Insurability) when you apply for coverage. The EoI covers your medical history, previous ailments, etc. If you don’t provide the information, your coverage will be denied.

Then when you make a claim, the insurance company will carefully examine your claim and the medical records for that claim to determine if the underlying condition existed prior to your receiving coverage. If that is the case, they will deny your claim.


It’s like the Equifax of medical insurance. I suppose if you paid cash in Tijuana you’d be in the clear, but if you ever get treated through insurance MIB likely knows about it.

The system is still ripe for abuse, though. You could avoid buying insurance for years and wiat until you’re really sick. Then you leave all your IDs at home, go the emergency room when, get diagnosed with Type II diabetes, and call up an insurance company the next day and say you’re perfectly healthy. Until a week later when Surprise! you suddenly have type II diabetes and need thousands of dollars worth of treatment even though you’ve paid nothing into the system. You could save a lot of money on health insurance that way, but at great risk to your own health of course. And since people undoubtedly do stuff like this, insurance companies have a vested interest in checking out your background any way they can.

No reputable insurance company is going to cover someone without previous coverage unless you provide an EoI, which is going to require a recent doctor’s visit, which is going to reveal your diabetes.

Legitimate question – does it count as a pre-existing condition if you didn’t know about it? I was under the impression that it had to be documented somewhere. It would suck to apply for insurance and find out that a) you had a disease you didn’t know about and b) you couldn’t get insurance because of it. Seems like a double whammy of suck.

eta: Answered my own question

So if you successfully lie about your previous trip to the ER, it doesn’t matter that the EoI exam reveals your diabetes. It shouldn’t count against you. Unless I misunderstand.

Yes, you don’t have to know about it. Let’s say you decide to get insurance because you don’t have any. You go to State Farm or Aetna or whoever and they say “Sure, you can have insurance, just fill out this Evidence of Insurability.” The form is going to ask you when your last checkup was, and if it wasn’t recent, the carrier is going to ask you to go get checked out first (yes, before you have any insurance to cover it). The doctor says, “Sorry steronz, you have uncontrolled diabetes and high blood pressure and you’re 40 lbs overweight.”

Well that news sucks, but it also means that State Farm isn’t going to give you coverage or, if they do, it will be for an unaffordable premium. So it is a double whammy of suck for you.

That’s one of the biggest selling points of the new health care reform package – even with your health problems, the insurance company would have to take you on. The only way they can afford to do that, though, is if all healthy people are also required to buy insurance.

Sorry, I replied before I saw your edit. Let me clarify.

If the insurance company gives you coverage and then discovers a condition that was undiagnosed when your coverage started, it will be covered (per your links) although some policies have exceptions for this.

But, generally, the insurance company is not going to give you coverage in the first place unless they are reasonably comfortable that you don’t have any serious conditions already. Hence the normal requirement that you provide evidence of your good health before they will give you coverage.

However, if the doctor DOESN’T catch something (say, some rare cancer that ordinarily isn’t checked for because the test costs $1000 and its yearly occurrence is 1 per million people), and State Farm gives you the insurance, and you are later diagnosed, and the doctor determines that, based on the examination, you had it before the insurance kicked in, it’s not a preexisting condition within the definiton of that term as used in insurance.

This should be moved to IMHO.

While, in theory, you only have a preexisting condition if it was diagnosed before you applied for the insurance, insurance companies often use “rescission” to deny claims. Thus, they will look for trivial discrepancies in your EoI – often not relevant to your current condition – and use that as an excuse to deny coverage. There have been many examples:

There was also the case of an insurance company targeting breast cancer patients to see if there was anything in their history that would allow them to drop coverage. Insurance officials were rewarded for the amount of money saved that way.

The new law has outlawed rescission except when fraud is involved.

That is correct, but it is not the same as trying to “trick” the insurance company into covering something you were already aware of.

I’m not sure why this isn’t the correct forum unless we start giving our opinions of the insurance business.

I wonder about this too. I had a heart attack last year, was completely covered by my employer’s insurance. If I ever switch jobs, does that make me uninsurable with my new employer’s health plan? Can I never switch jobs for fear of losing my health insurance?

Group plans provided by employers don’t have the pre-existing condition exclusion. (I think they’re actually required not to.) All regular employees of a company will have access to the plan at the same rates.

Pre-existing conditions generally only come into play when trying to get an individual policy or extra coverage.

Anyone have any thoughts/experience to my Q. of when the condition factually/medically kicks in, in the case of progressive things like fat----->insulin resistant------>really insulin resistant and taking oral meds----->type II diabetes w/injections? At which point would you, as a new applicant, be ineligible for covered “diabetes treatment” based on preexisting condition?

Also, pre-existing exclusions don’t come into play if you have had previous insurance with no break in coverage.

I don’t think you’re going to get a satisfying answer, because it depends on your specific medical history and on the insurance company. If you go to a doctor and he mentions in passing that you’re at a high risk of developing diabetes, that probably won’t make it to the MIB. If he prescribes you a drug that’s known to delay the onset of diabetes, you may be screwed. Apparently (per Skammer’s informative posts upthread) an insurance company can deny you coverage for any reason at all, so if they so much as get a hunch that you’re going to be costly, they can either jack up the rates or deny you coverage altogether.

They will affect the amount of the premium, though.