Claim case sharing
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:
- that has been diagnosed prior to commencement of the policy
- that has been treated or advised to be treated prior to commencement of the policy
- that has been investigated or advised to be investigated prior to commencement of the policy
- for which a patient has been given medication or advised to have medication prior to commencement of the policy
- for which a patient has symptoms that manifested prior to commencement of policy
- for which a patient has been hospitalised or advised to be hospitalised prior to commencement of the policy
- that has been known to exist prior to commencement of the policy
- 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.