Pre-existing conditions clauses deal with those medical problems that you've been treated for in the past or in some cases even a condition you've never been treated for, but know or should know that you have.  The three main issues are:

• Can you get coverage?

• If you do get coverage, can and if so, for how long can the Insurance Company exclude coverage?

• If they can exclude coverage, must they cover you after a certain period of time and must they give you credit for time under your prior coverage?

See the FAQ's below.  If you are in California, email us a copy of your policy, application, etc. and we can help you.

FAQ's
Frequently Asked Questions

How can I get Individual or Family Coverage?

1. Is there a simple ONE page form that I can fill out to see if my Medical conditions will still allow me to get Preferred Rates for Individual Coverage?
   California Residents ONLY.

2. What about Guaranteed Issue plans, like:
   Health Care Reform's Pre-Existing Condition Plan
   Mr. MIP
   
   or limited benefit plans like Get Med 360?
   

3. What about BMI and weight?

4. What if I do not tell the Insurance company about my medical conditions?

5. Does the Government have any tools to help me find coverage?

6. What about the new rule that kids under 19 cannot have a Pre X clause?

7. What if I'm pregnant?

What is a Pre Existing Condition?

1. What medical issues might be considered  Pre - Existing?
2. What State or Federal Laws Define "Pre-Existing Condition?"
3. What if I paid cash and there is no record of my illness or treatment?
4. Does the Dept of Labor have a brochure to explain how HIPAA protects on Pre-X conditions?
   
5. wikipedia.org

Employer Group Coverage?

1. Does AB 1672 in CA require Employer's Group health plans, including if I start my own business have to write my coverage, and waive the Pre-existing Condition clause?

2. Are there any rules or laws  that say the Insurance Company must cover my Pre-X immediately if I pass underwriting or the Insurance Company is mandated to issue coverage to me.
   employee in an Employer Group Plan
   AB 1672
   AB 1790?

3. If I lost my coverage from my job, are there any guarantees?
   COBRA
   Cal COBRA
   HIPAA When Cal Cobra is all used up.

Seniors & Medicare

1. What about Medicare Advantage & Medi Gap (Supplement) plans?

Waiving the Pre X Clause - Once I'm able to get coverage

1. If I have prior medical insurance "Credible Coverage" and I get new health coverage will my  pre-existing conditions be covered?

2. If I do not have prior Credible Coverage will  my pre-x be excluded forever, or just for say 6 months or a year

3. What about the Pre X clause in visitor and travel policies?

Claims Issues?

1. What if something else makes the Pre-X worse, my pre-x causes a new problem, that is, how does the Insurance Company decide if the medical expense claim was from the Pre-X?
2. What if I have say Hypertension - how would it be determined if that was the nexus or aggravation of say a Heart Attack?
3. If I have a policy in force and then I get sick or develop a Pre - X  can they cancel me or raise my rates?
4. How can I appeal, complain or file a grievance?

5. Does Obama's Plan prohibit recessions Nationally?

    

Misc.

1. Where can I find Federal Regulations §146.111 or §2590.701-3 on Pre-X limitations?

2. How will Obama's Plan affect Pre-Existing Conditions?

3. How do I get help if I'm not in California?

4. Are there any Federal, State AB 88 or protections in Obama's plan for Mental Illness?

State & Federal Laws that Define Pre-Existing Conditions top

"Pre-existing condition provision" means a policy provision that excludes coverage for charges or expenses incurred during a specified period following the insured's effective date of coverage, as to a condition for which medical advice, diagnosis, care, or treatment was recommended or received during a specified period immediately preceding the effective date of coverage.  
California Small Group Employer Plans AB 1672
CA Ins. Code  §10700 (q)
Appears to be exact same definition as in CA  Ins. Code §   10198.6 c
 Federal Definition Title 42 300 gga
wikipedia.org

Also check the application for a definition of Pre X or what the health questions are.

Web MD

Knox Keene Health Care Act

Underwriting top

In Individual plans Insurance Companies generally have the right to decide to give you a policy on not.  This is called Underwriting. 

Listingof  typical Pre-existing conditions

If there are any waiting periods in your new coverage, they are generally waived if 63 days of terminating your Insurance with another "creditable" health care plan.

One Page - Pre Underwriting FORMS

Do NOT miss your HIPAA 63 day deadline!

Pre-Clause Waived if you had Prior Coverage top

If you apply for coverage within 63 days of terminating your membership with another "creditable" health care plan, then you can use your prior coverage for credit toward the six-month waiting period.  
 CA Insurance Code for Small Group Plans 10708 c
Individual Plans CA Insurance Codes §10198.6-10198.9 (might not be on point)   Blue Shield FAQ's PPO Share Brochure - Page 12
 Federal Guarantees
HIPAA Health Insurance Portability and Accountability Act

When must a health plan write me? top

In CA under AB 1672 Small Employer Health Act §10705 j you can not be excluded as an employee or dependent in a group plan for health status.   Employer group of 2 or more are guaranteed coverage.

Mr. MIP Guaranteed coverage for individuals rejected from standard plans.

Obama's Interium High Risk Guaranteed Pool

Guaranteed Issue & Plans for Uninsured

Federal Law 1182 - Group Plans must treat all simlarly situated employees the same, regardless of health status.

Steve, you're website is the greatest, but I don't live in California   top

Guarantees for those who lost Employer Group Health Insurance  top

COBRA
 and when that expires in 18 months or 36 months in California,
 then you can get a "HIPAA" policy

HIPAA Matrix
 

Weight Chart  top

This is NOT an Insurance Company Chart.  We just have it here for guidance.  Check our Pre-Underwriting Page for a more specific answer to your medical situation.

www.health.harvard.edu/

How long is the Pre-X clause?  top

In CA Group Plans, not more than 6 months 10198.7

This clause can often be waived!

Government Tools to help find coverage   top

Case Law on Pre-Existing Conditions top

10198.6.  Preexisting Condition Provisions and Late Enrollees
                   10198.6-10198.9

For purposes of this article:
   (a) "Health benefit plan" means any group or individual policy or
contract that provides medical, hospital, or surgical benefits. The
term does not include accident only, credit, disability income,
coverage of Medicare services pursuant to contracts with the United
States government, Medicare supplement, long-term care insurance,
dental, vision, coverage issued as a supplement to liability
insurance, insurance arising out of a workers' compensation or
similar law, automobile medical payment insurance, or insurance under
which benefits are payable with or without regard to fault and that
is statutorily required to be contained in any liability insurance
policy or equivalent self-insurance.
   (b) "Late enrollee" means an eligible employee or dependent who
has declined health coverage under a health benefit plan offered
through employment or sponsored by an employer at the time of the
initial enrollment period provided under the terms of the health
benefit plan, and who subsequently requests enrollment in a health
benefit plan of that employer; provided that the initial enrollment
period shall be a period of at least 30 days. However, an eligible
employee or dependent shall not be considered a late enrollee if any
of the following is applicable:
   (1) The individual meets all of the following requirements:
   (A) The individual was covered under another employer health
benefit plan, the Healthy Families Program, the Access for Infants
and Mothers (AIM) Program, or the Medi-Cal program at the time the
individual was eligible to enroll.
   (B) The individual certified, at the time of the initial
enrollment that coverage under another employer health benefit plan,
the Healthy Families Program, the AIM Program, or the Medi-Cal
program was the reason for declining enrollment provided that, if the
individual was covered under another employer health benefit plan,
the individual was given the opportunity to make the certification
required by this subdivision and was notified that failure to do so
could result in later treatment as a late enrollee.
   (C) The individual has lost or will lose coverage under another
employer health benefit plan as a result of termination of employment
of the individual or of a person through whom the individual was
covered as a dependent, change in employment status of the individual
or of a person through whom the individual was covered as a
dependent, termination of the other plan's coverage, cessation of an
employer's contribution toward an employee or dependent's coverage,
death of a person through whom the individual was covered as a
dependent, legal separation, divorce, loss of coverage under the
Healthy Families Program , the AIM Program, or the Medi-Cal program.
   (D) The individual requests enrollment within 30 days after
termination of coverage, or cessation of employer contribution toward
coverage provided under another employer health benefit plan, or
requests enrollment within 60 days after termination of Medi-Cal
program coverage, AIM Program coverage, or Healthy Families Program
coverage.
   (2) The individual is employed by an employer that offers multiple
health benefit plans and the individual elects a different plan
during an open enrollment period.
   (3) A court has ordered that coverage be provided for a spouse or
minor child under a covered employee's health benefit plan.
   (4) The carrier cannot produce a written statement from the
employer stating that, prior to declining coverage, the individual or
the person through whom the individual was eligible to be covered as
a dependent was provided with, and signed acknowledgment of,
explicit written notice in boldface type specifying that failure to
elect coverage during the initial enrollment period permits the
carrier to impose, at the time of the individual's later decision to
elect coverage, an exclusion from coverage for a period of 12 months
as well as a six-month preexisting condition exclusion, unless the
individual meets the criteria specified in paragraph (1), (2), or
(3).
   (5) The individual is an employee or dependent who meets the
criteria described in paragraph (1) and was under a COBRA
continuation provision and the coverage under that provision has been
exhausted. For purposes of this section, the definition of "COBRA"
set forth in subdivision (e) of Section 10116.5 shall apply.
   (6) The individual is a dependent of an enrolled eligible employee
who has lost or will lose his or her coverage under the Healthy
Families Program, the AIM Program, or the Medi-Cal program and
requests enrollment within 60 days of termination of that coverage.
   (c) "Preexisting condition provision" means a policy provision
that excludes coverage for charges or expenses incurred during a
specified period following the insured's effective date of coverage,
as to a condition for which medical advice, diagnosis, care, or
treatment was recommended or received during a specified period
immediately preceding the effective date of coverage.
   (d) "Creditable coverage" means:

(1) Any individual or group policy, contract or program, that is
written or administered by a disability insurance company, health
care service plan, fraternal benefits society, self-insured employer
plan, or any other entity, in this state or elsewhere, and that
arranges or provides medical, hospital, and surgical coverage not
designed to supplement other private or governmental plans. The term
includes continuation or conversion coverage but does not include
accident only, credit, coverage for onsite medical clinics,
disability income, Medicare supplement, long-term care insurance,
dental, vision, coverage issued as a supplement to liability
insurance, insurance arising out of a workers' compensation or
similar law, automobile medical payment insurance, or insurance under
which benefits are payable with or without regard to fault and that
is statutorily required to be contained in any liability insurance
policy or equivalent self-insurance.
   (2) The federal Medicare program pursuant to Title XVIII of the
Social Security Act.
   (3) The medicaid program pursuant to Title XIX of the Social
Security Act.
   (4) Any other publicly sponsored program, provided in this state
or elsewhere, of medical, hospital and surgical care.
   (5) 10 U.S.C. Chapter 55 (commencing with Section 1071) (Civilian
Health and Medical Program of the Uniformed Services (CHAMPUS)).
   (6) A medical care program of the Indian Health Service or of a
tribal organization.
   (7) A state health benefits risk pool.
   (8) A health plan offered under 5 U.S.C. Chapter 89 (commencing
with Section 8901) (Federal Employees Health Benefits Program
(FEHBP)).
   (9) A public health plan as defined in federal regulations
authorized by Section 2701(c)(1)(I) of the Public Health Service Act,
as amended by Public Law 104-191, the Health Insurance Portability
and Accountability Act of 1996.
   (10) A health benefit plan under Section 5(e) of the Peace Corps
Act (22 U.S.C. Sec. 2504(e)).
   (11) Any other creditable coverage as defined by subsection (c) of
Section 2701 of Title XXVII of the federal Public Health Services
Act (42 U.S.C. Sec. 300gg(c)).
   (e) "Affiliation period" means a period that, under the terms of
the health benefit plan, must expire before health care services
under the plan become effective.
   (f) "Waivered condition" means a contract provision that excludes
coverage for charges or expenses incurred during a specified period
of time for one or more specific, identified, medical conditions.




10198.61.  (a) For purposes of this article, "health benefit plan"
does not include policies or certificates of specified disease or
hospital confinement indemnity provided that the carrier offering
those policies or certificates complies with the following:
   (1) The carrier files, on or before March 1 of each year, a
certification with the commissioner that contains the statement and
information described in paragraph (2).
   (2) The certification required in paragraph (1) shall contain the
following:
   (A) A statement from the carrier certifying that policies or
certificates described in this section (i) are being offered and
marketed as supplemental health insurance and not as a substitute for
hospital or medical expense insurance, health care service plans, or
major medical expense insurance, (ii) the disclosure forms as
described in Section 10603 contains the following statement
prominently on the first page: "This is a supplement to health
insurance. It is not a substitute for hospital or medical expense
insurance, a health maintenance organization (HMO) contract, or major
medical expense insurance," and (iii) are not being offered,
marketed, or sold in a manner that would make the purchase of the
policies contingent upon the sale of any product sold under Sections
10700 and 10718, or under Section 1357 of the Health and Safety Code.
   (B) A summary description of each policy or certificate described
in this section, including the average annual premium rates, or range
of premium rates in cases where premiums vary by age, gender, or
other factors, charged for the policies and certificates in this
state.
   (3) In the case of a policy or certificate described in this
section and that is offered for the first time in this state on or
after January 1, 1997, the carrier files with the commissioner the
information and statement required in paragraph (2) at least 30 days
prior to the date such a policy or certificate is issued or delivered
in this state.
   (b) As used in this section, "policies or certificates of
specified disease" and "policies or certificates of hospital
confinement indemnity" mean policies or certificates of insurance
sold to an insured to supplement other health insurance coverage as
specified in this section. An insurer issuing a "policy or
certificate of specified disease" or a "policy or certificate of
hospital confinement indemnity" shall require that the person to be
insured is covered by an individual or group policy or contract that
arranges or provides medical, hospital, and surgical coverage not
designed to supplement other private or governmental plans.



10198.7.  (a) No health benefit plan that covers three or more
persons and that is issued, renewed, or written by any insurer,
nonprofit hospital service plan, self-insured employee welfare
benefit plan, fraternal benefits society, or any other entity shall
exclude coverage for any individual on the basis of a preexisting
condition provision for a period greater than six months following
the individual's effective date of coverage, nor shall limit or
exclude coverage for a specific insured person by type of illness,
treatment, medical condition, or accident except for satisfaction of
a preexisting clause pursuant to this article. Preexisting condition
provisions contained in health benefit plans may relate only to
conditions for which medical advice, diagnosis, care, or treatment,
including use of prescription drugs, was recommended or received from
a licensed health practitioner during the six months immediately
preceding the effective date of coverage.
   (b) No health benefit plan that covers one or two individuals and
that is issued, renewed, or written by any insurer, self-insured
employee welfare benefit plan, fraternal benefits society, or any
other entity shall exclude coverage on the basis of a preexisting
condition provision for a period greater than 12 months following the
individual's effective date of coverage, nor shall limit or exclude
coverage for a specific insured person by type of illness, treatment,
medical condition, or accident, except for satisfaction of a
preexisting condition clause pursuant to this article. Preexisting
condition provisions contained in health benefit plans may relate
only to conditions for which medical advice, diagnosis, care, or
treatment, including use of prescription drugs, was recommended or
received from a licensed health practitioner during the 12 months
immediately preceding the effective date of coverage.
   (c) A carrier that does not utilize a preexisting condition
provision may impose a waiting or affiliation period not to exceed 60
days, before the coverage issued subject to this article shall
become effective. During the waiting or affiliation period, the
carrier is not required to provide health care services and no
premium shall be charged to the subscriber or enrollee.
   (d) A carrier that does not utilize a preexisting condition
provision in health plans that cover one or two individuals may
impose a contract provision excluding coverage for waivered
conditions. No carrier may exclude coverage on the basis of a
waivered condition for a period greater than 12 months following the
individual's effective date of coverage. A waivered condition
provision contained in health benefit plans may relate only to
conditions for which medical advice, diagnosis, care, or treatment,
including use of prescription drugs, was recommended or received from
a licensed health practitioner during the 12 months immediately
preceding the effective date of coverage.
   (e) In determining whether a preexisting condition provision, a
waivered condition provision, or a waiting or affiliation period
applies to any person, all health benefit plans shall credit the time
the person was covered under creditable coverage, provided the
person becomes eligible for coverage under the succeeding health
benefit plan within 62 days of termination of prior coverage,
exclusive of any waiting or affiliation period, and applies for
coverage under the succeeding plan within the applicable enrollment
period. A health benefit plan shall also credit any time an eligible
employee must wait before enrolling in the health benefit plan,
including any affiliation or employer-imposed waiting period.
However, if a person's employment has ended, the availability of
health coverage offered through employment or sponsored by an
employer has terminated or, an employer's contribution toward health
coverage has terminated, a carrier shall credit the time the person
was covered under creditable coverage if the person becomes eligible
for health coverage offered through employment or sponsored by an
employer within 180 days, exclusive of any waiting or affiliation
period, and applies for coverage under the succeeding plan within the
applicable enrollment period.
   (f) No health benefit plan that covers three or more persons and
that is issued, renewed, or written by any insurer, nonprofit
hospital service plan, self-insured employee welfare benefit plan,
fraternal benefits society, or any other entity may exclude late
enrollees from coverage for more than 12 months from the date of the
late enrollee's application for coverage. No insurer, nonprofit
hospital service plan, self-insured employee welfare benefit plan,
fraternal benefits society, or any other entity shall require any
premium or other periodic charge to be paid by or on behalf of a late
enrollee during the period of exclusion from coverage permitted by
this subdivision.
   (g) An individual's period of creditable coverage shall be
certified pursuant to subdivision (e) of Section 2701 of Title XXVII
of the federal Public Health Services Act, 42 U.S.C. Sec. 300gg(e).
   (h) A group health benefit plan may not impose a preexisting
condition exclusion to any of the following:
   (1) To a newborn individual, who, as of the last day of the 30-day
period beginning with the date of birth, applied for coverage
through the employer-sponsored plan.
   (2) To a child who is adopted or placed for adoption before
attaining 18 years of age and who, as of the last day of the 30-day
period beginning with the date of adoption or placement for adoption,
is covered under creditable coverage and applies for coverage
through the employer-sponsored plan. This provision shall not apply
if, for 63 continuous days, the child is not covered under any
creditable coverage.
   (3) To a condition relating to benefits for pregnancy or maternity
care.
   (i) Any entity providing aggregate or specific stop loss coverage
or any other assumption of risk with reference to a health benefit
plan shall provide that the plan meets all requirements of this
article concerning waiting periods, preexisting condition provisions,
and late enrollees.



10198.8.  This article applies to all health benefit plans that
provide hospital, medical, or surgical benefits to residents of this
state regardless of the situs of the contract or group master
policyholder.


10198.9.  (a) Except in the case of a late enrollee, or for
satisfaction of a preexisting condition clause in the case of initial
coverage of an eligible employee, a disability insurer may not
exclude any eligible employee or dependent who would otherwise be
entitled to health care services on the basis of any of the
following: the health status, the medical condition, including both
physical and mental illnesses, the claims experience, the medical
history, the genetic information, or the disability or evidence of
insurability, including conditions arising out of acts of domestic
violence of that employee or dependent. No health benefit plan may
limit or exclude coverage for a specific eligible employee or
dependent by type of illness, treatment, medical condition, or
accident, except for preexisting conditions as permitted by Section
10198.7.
   (b) For purposes of this section, "health benefit plan" shall have
the same meaning as in Section 10198.6 and subdivision (a) of
Section 10198.61.
   (c) For purposes of this section, "eligible employee" shall have
the same meaning as in Section 10700 except that it shall apply to
any health benefit plan covering two or more eligible employees.

 top

Is one condition the nexus or aggravation of another?  top

Lastly, the veteran must have a nexus [connection]  between the current disability and the in service disease injury or incident.

In other words, there must be a link between the present disability and the veterans time during his period of active military service.

There are many ways in which the veterans present disability can be connected to his disease, injury or incident in service. The VA is required to consider all the possible ways to disability could be service-connected.

Probably the most common is direct service connection. This is when a disease, injury or incident in service directly caused the veteran's present disability. These cases are usually won when you have a letter from a doctor stating that the in service disease, injury or incident was the cause of the veteran's present disability. Because the veteran is given the benefit of the doubt a doctor only needs to be 50% sure that the in service condition caused the present disability. The language the VA accepts is that it is "at least as likely as not" that the veterans present disability is a result of the specified disease injury or incident in service. If the doctor uses the terminology that it is less likely than not he or she is saying they are less than 50% sure there is a connection. And if the doctor uses the terminology that "it is more likely than not" then he or she is saying there is a greater than 50% chance that the in service disease injury or incident caused the veterans present disability. These opinions from doctors are often called Nexus letters. If you are seeking a nexus opinion from your doctor it is extremely important the doctor is aware of the terminology used by the VA. It is also important for these opinion letters that the doctor have access to, review and state that he has reviewed your file and service medical records. If the doctor references the file in service medical records it strengthens the opinion even more. These opinion letters are even more important when you're trying to prove service connection for a present condition many years after service.

A veteran will have to show aggravation of a condition in service if the condition preexisted his service time. If the veteran can show his condition has worsened as a result of his time in service than the VA has the burden to prove that the worsening of the condition was due to "the natural progression of the disease." One presumption in VA law that helps in these types of cases is the "presumption of soundness." This means the veteran is presumed to be in sound condition when he entered service in less shown otherwise usually by the service entrance exam
icdri.org/

rbs law.com/

veterans disability lawyer site.com

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