How do I know if I’m covered? Understanding pre-existing condition limitations

Do you ever find yourself wondering, what’s the catch? When it comes to insurance plans, understanding your coverage is important, but being aware of any exceptions to that coverage is critical. Most policies have a section called ‘exclusions and limitations,’ which limits the amount of coverage that may be available under the policy. One limitation in particular you may come across when reviewing your plan is for ‘pre-existing conditions.’


Most people who are familiar with pre-existing condition limitations might associate them with health insurance, but they can also apply to other types of insurance— such as short-term disability, long-term disability, and critical illness insurance—so it is important to understand what a pre-existing condition is and how it may affect your coverage. But how do you know if you have a pre-existing condition?

Here’s how it works: first, a pre-existing condition is defined as, if during the time period outlined in the policy—often 3 months—prior to your effective date of coverage, you:

  • received medical treatment, consultation, care, or services (including diagnostic measures) for the condition, or
  • took prescribed drugs or medicines for the condition.

So, using a timeline:

To reiterate, the pre-existing-condition limitation will not apply if your condition begins later than the timeframe outlined in your policy—often 12 months—after the effective date of coverage.

To determine if you are subject to a pre-existing condition limitation and how it may affect your coverage, consult your insurance policy or certificate for the definition of pre-existing condition.

Having a general understanding of what a pre-existing condition is and how it can apply to you can be helpful as you evaluate your insurance coverage options. If you have questions about your coverage specifically, please contact your benefits administrator.

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