Pre-existing medical conditions

Health and travel insurers generally don’t provide cover for claims related to pre-existing medical conditions. Read this guide to find out what to do to avoid problems. 

What are pre-existing medical conditions?

Pre-existing conditions are medical conditions that exist at the time you arrange your insurance. 

Different insurance policies will contain different definitions of a pre-existing condition. The definition can include a symptom, a sign, or a circumstance of the condition being present at the time you take out the policy, rather than requiring a diagnosis of the condition itself. That means a symptom can be a pre-existing condition, even if you do not have a specific diagnosis. Check your policy to understand the definition that applies to you. 

Why is it an issue for consumers?

Health and travel insurance policies usually contain exclusions for pre-existing conditions. This means if a claim relates to a pre-existing condition, the insurer will probably not accept the claim. This can result in unexpected costs and stress for the insured person, particularly if medical attention is required while overseas.   

No cover for knee replacement pre existing condition

Real life examples

Mae’s* declined ambulance costs

Mae took her daughter, Eve* to Australia to see a nutritional expert about Eve’s food allergies, psychiatric disorder, and hyperventilation syndrome. During the trip, Eve collapsed at a restaurant and was taken to hospital in an ambulance. Mae made a claim for the cost of the ambulance trip. 

The insurer declined the claim, because it arose from a pre-existing condition. Mae said Eve hadn’t been diagnosed with any condition when she arranged the policy. However, this was not the policy definition of a pre-existing condition. Eve had a long history of doctor visits and hospital admissions for food allergies, psychiatric episodes, collapsing and hyperventilation issues. The insurer was able to decline the claim based on the pre-existing condition exclusion. 

Kate’s* bad knee

Kate made a claim for knee replacement surgery as a result of osteoarthritis. The insurer reviewed Kate’s medical history and found that there were medical records confirming the knee had degenerative changes noted as far back as 15 years earlier. The insurer declined the claim based on a pre-existing condition exclusion. Kate acknowledged that the condition of osteoarthritis existed prior to her taking out the policy and understood why cover was not available for her surgery. 

Roger’s* policy waiver applied to holiday claim

Paul* had to postpone his overseas trip after his father, Roger (who had bowel cancer and renal failure), fell out of bed, was admitted to hospital, and died. Paul made a travel insurance claim for his non-refundable accommodation costs. The insurer relied on a pre-existing condition exclusion for Roger to decline the claim. However, the policy contained a waiver for the exclusion, if Roger’s condition was stable. Paul provided medical evidence confirming Roger’s condition was stable and the insurer agreed to pay the claim.   

*Names have been changed

See more cases about non-disclosure

Things to know about pre-existing medical conditions

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  1. Why insurers exclude pre-existing conditions

    Health insurance (including medical cover in travel insurance) is designed to cover health conditions that arise after the start date of the policy. This is how the insurer is able to assess its risk and determine the policy premiums. 

    Pre-existing conditions can increase the risk of a claim being made. Insurers often include a pre-existing condition exclusion in the policy to limit this risk. 

  2. You can ask your insurer to provide cover for your pre-existing conditions

    When you arrange the policy, you should tell your insurer about all pre-existing conditions you are aware of. This includes telling your insurer about symptoms you have, even if you haven’t received a formal diagnosis. For example, if you had been to your doctor for knee pain but did not know what was causing it, tell your insurer. You can ask your insurer to provide cover for your pre-existing conditions. 

    The insurer will let you know if it requires any further information, like a medical certificate. It will then confirm whether it will provide cover for your pre-existing condition. 

    If the insurer agrees to provide cover for a pre-existing condition, you will probably need to pay a higher premium to reflect the higher risk associated with your condition.

  3. I didn’t know I had a pre-existing condition – does the exclusion still apply?

    The policy definition and wording of the pre-existing condition exclusion will confirm whether your knowledge of a pre-existing condition is relevant to the claim decision. You can ask your insurer to explain the wording of your policy and provide reasons why it thinks a pre-existing condition exclusion applies. 

  4. My claim has been declined – what do I do now?

    You can request a review of the claim decision through your insurer’s internal complaints process. If you are unhappy with the complaint response, you can ask the IFSO Scheme to investigate your complaint, for free. 

  5. Think carefully before changing health insurance providers

    If you have held a health insurance policy with an insurer for a long time, think carefully before you change to a different insurer. 

    If you have developed medical conditions after you first took out the policy, these will generally be covered under your existing policy. But if you change to a new insurer, the new insurer will probably consider these to be pre-existing conditions under the new policy and claims relating to these conditions could be declined. 

    You will need to request cover for your pre-existing conditions as part of the application process for any new health insurance. 

Tips to avoid problems

Disclose any pre-existing conditions to the insurer when you arrange the policy

Answer all the questions about your medical history when completing your insurance application, even if you think it may not be relevant. It’s important to tell the insurer everything, even something as simple as having felt depressed or having a sore back that you may have discussed with your doctor. 

Health policies also require you to tell the insurer about anything that happens between completing your application and the insurance cover starting. This means if you visit the doctor, develop a health problem, or your situation changes after you complete the application and before your insurance cover begins, you must tell your insurer.

Read your policy

Read your policy wording carefully to understand what cover, if any, is provided for pre-existing conditions. Take a look at the policy definition of a pre-existing condition and the exclusion wording.

Talk to your insurer if you have any questions

If you are unsure if your circumstances are covered by the policy, talk to your insurer which will be able to provide more information. 

Let your insurer know any changes when you renew your insurance

When you renew house, contents or vehicle insurance, tell the insurer about any events (convictions, speeding, accidents, losses, etc) that have happened since the last renewal.

Ask if you can’t remember

If you can’t remember your full medical history, ask your doctor for a copy of your medical notes, and double-check the insurance application. In some cases, it may be appropriate to provide the insurer with your medical notes.