Pre-Existing Condition Exclusion Period

A Pre-Existing Condition Can Affect Your Health Insurance Coverage

Woman using inhaler on the beach
Asthma can be considered a pre-existing condition.. Westend61/Getty Images

A pre-existing condition can affect your health insurance coverage. If you are applying for insurance, some health insurance companies may accept you conditionally by providing a pre-existing condition exclusion period.

Although the health plan has accepted you and you are paying your monthly premiums, you may not have coverage for any care or services related to your pre-existing condition. This means that any new, non-related health issues that arise will be covered by the health insurance company, but any health issues that arise directly as a result of the pre-existing condition will not be covered.

The period of time of a pre-existing condition exclusion period varies. Depending on the particular policy and your state’s insurance regulations, this exclusion period can range from six to 18 months.

If you are getting insurance at your job, depending on your employer and the health plans offered, you may have a pre-existing exclusion period. However, the exclusion period is limited to 12 months (18 months if you enrolled late in the health plan) and only applies to health conditions for which you sought treatment in the 6 months before you enrolled in the health plan.

Pre-Existing Condition

A pre-existing condition is a health problem that existed before you apply for a health insurance policy or enroll in a new health plan. Failure to properly disclose a pre-existing condition to your health insurance provider could lead to issues with coverage and service.

Basically any medical issue can fall under the umbrella of a pre-existing condition.

Pre-existing conditions can range from something as common as asthma to something as serious as heart disease, cancer, and type 2 diabetes. Such chronic health problems that affect a large portion of the population are all considered to be pre-existing conditions.

Affordable Care Act

The Affordable Care Act altered the way pre-existing conditions are handled in the United States.

Now, thanks to the Act, health insurers can’t take your health history into account when deciding whether or not to sell you a health insurance policy. They cannot exclude a pre-existing condition from coverage, nor can they charge you more because you have a pre-existing condition.

More Information from Dr. Mike

· Pre-Existing Conditions - Understanding Exclusions and Creditable Coverage


Mike J. recently got a new job after being unemployed for almost a year. His new company allows employees to participate in its health plan at the end of the first pay period. Mike has mild asthma. In the six months prior to the time he enrolled in his employer’s health plan, he had no doctor visits and did not take any medication. He was not subject, therefore, to any exclusion period for his pre-existing conditions. Shortly after he started working, his asthma worsened – he was fully covered for all of his asthma-related care.

Continue Reading