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Pre-existing condition


In the context of healthcare in the United States, a pre-existing condition is a medical condition that started before a person's health insurance went into effect. Before 2014 some insurance policies would not cover expenses due to pre-existing conditions. These exclusions by the insurance industry were meant to cope with adverse selection by potential customers. Such exclusions are prohibited after January 1, 2014, by the Patient Protection and Affordable Care Act.

The University of Pittsburgh Medical Center defines a pre-existing condition as a "medical condition that occurred before a program of health benefits went into effect". J. James Rohack, president of the American Medical Association, has stated on a Fox News Sunday interview that exclusions, based upon these conditions, function as a form of "rationing" of health care.

Conditions can be broken down into two further categories, according to Lisa Smith of Investopedia:

Most insurance companies use one of two definitions to identify such conditions. Under the "objective standard" definition, a pre-existing condition is any condition for which the patient has already received medical advice or treatment prior to enrollment in a new medical insurance plan. Under the broader, "prudent person" definition, a pre-existing condition is anything for which symptoms were present and a prudent person would have sought treatment.

Which definition may be used was sometimes regulated by state laws. Some states required insurance companies to use the objective standard, while others required the prudent person standard. 10 states did not specify either definition, 21 required the "prudent person" standard, and 18 required the "objective" standard.

Regulation of pre-existing condition exclusions in individual (non-group) and small group (2 to 50 employees) health insurance plans in the United States is left to individual U.S. states as a result of the McCarran–Ferguson Act of 1945 which delegated insurance regulation to the states and the Employee Retirement Income Security Act of 1974 (ERISA) which exempted self-insured large group health insurance plans from state regulation. After most states had by the early 1990s implemented some limits on pre-existing condition exclusions by small group (2 to 50 employees) health insurance plans, the Health Insurance Portability and Accountability Act (Kassebaum-Kennedy Act) of 1996 (HIPAA) extended some minimal limits on pre-existing condition exclusions for all group health insurance plans—including the self-insured large group health insurance plans that cover half of those with employer-provided health insurance but are exempt from state insurance regulation.


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