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How does an insurance company determine pre-existing conditions - Part B

In previous issues, we discussed general areas for consideration in determining a pre-existing condition. In this issue, we are going to discuss two more areas of the same topic.

  1. Is the condition a continuation of a previous condition or a separate disability?

    Even for conditions that might be chronic, we have to examine whether two occurrences are the result of the same disability or not.

    For example, if a back problem was treated and then remained free of symptoms for two years without any residual physical abnormality and with no follow-up treatment or monitoring being required, it should not be treated as a pre-existing condition even if it occurs again after the policy becomes effective.

  2. Frequency and severity of episodes

    With medical conditions or symptoms that occur as single or infrequent episodes, we should not jump to the conclusion of a pre-existing condition too early.

    For example, a person who had diarrhoea twice just one month before the policy effective date was found to have CA rectum 2 months after the effective date. We cannot establish that the 2 episodes of diarrhoea one month ago resulted from CA rectum and conclude that CA rectum is pre-existing.

    However, if a person with a history of diarrhoea with blood twice occurring one month before the policy effective date was found to have CA rectum 2 months after the effective date, excluding any haemorroids or without other rectal abnormalities being detected, we may say that the 2 episodes of diarrhoea with blood one month ago might be closely related to CA rectum and that the CA rectum may be pre-existing. But the final decision should be based on a doctor's professional observations.

    Conversely speaking, if the diarrhoea had been persistent for 1-2 months before CA rectum was detected, no matter with or without blood, we can suspect that the persistent diarrhoea was related to CA rectum.

As there are so many criteria for determining whether or not a condition is pre-existing, in order to arrive at a fair decision, insurance companies will judge each individual case carefully based on relevant medical reports.

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