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

All kinds of insurances deal with pre-existing conditions - not just health and personal accident insurance - and the definition of pre-existing conditions varies from company to company.

Generally speaking, for medical insurance, any condition for which a person is receiving treatment, has been advised to receive treatment, or for which a prudent person would seek treatment, be it congenital or acquired and regardless of whether the condition is diagnosed or not before the policy becomes effective, is a pre-existing condition.

A reasonable interpretation of pre-existing conditions is any injury, illness, disease, sickness, medical condition or symptom:

  1. that has been diagnosed prior to commencement of the policy
  2. that has been treated or advised to be treated prior to commencement of the policy
  3. that has been investigated or advised to be investigated prior to commencement of the policy
  4. for which a patient has been given medication or advised to have medication prior to commencement of the policy
  5. for which a patient has symptoms that manifested prior to commencement of policy
  6. for which a patient has been hospitalised or advised to be hospitalised prior to commencement of the policy
  7. that has been known to exist prior to commencement of the policy
  8. that has a strong medical indication that it originated prior to the commencement of the policy, e.g. size of a tumour or stage of cancer

In addition to these factors, what else does an insurance company consider?

Is the condition acute or chronic?

An insurance company will not judge whether a condition is pre-existing solely by its name, as some conditions might be acute or chronic.

For example, some people might have gastroenteritis occasionally which is acute in nature. We cannot say that a person's gastroenteritis is pre-existing even if that person has had gastroenteritis before the policy became effective. The same interpretation is applied to chest infections, acute bronchitis, etc. However, if a person appears to have been suffering from chronic diarrhoea for a year - resulting in him/her having to rush to the bathroom every time he/she becomes nervous or is placed under pressure - then he/she is suffering from irritable bowel syndrome. If this has been happening regularly before the policy became effective, this will be regarded as a pre-existing condition.

In the next issue, we will discuss two more basic areas for consideration in determining a pre-existing condition.

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