Claim rejection for non-disclosure of pre-existing disease (PED) post-waiting period
What is Non-disclosure of pre-existing disease (PED)?
Non-disclosure of pre-existing disease (PED) refers to the failure of an individual to inform their insurance provider about any existing medical conditions or ailments they have at the time of purchasing an insurance policy. Pre-existing diseases are health issues or conditions that a person already has before obtaining insurance coverage. The insurance company relies on this information to assess the risk associated with insuring the individual.
Non-disclosure of pre-existing disease (PED) refers to the failure of an individual to inform their insurance provider about any existing medical conditions or ailments they have at the time of purchasing an insurance policy. Pre-existing diseases are health issues or conditions that a person already has before obtaining an insurance coverage. The insurance company relies on this information to assess the risk associated with insuring the individual.
Consider the scenario of Aditya, who, in 2010, purchased an insurance plan with the understanding that it would cover medical complications related to conditions like diabetes and hypertension after a waiting period of two years. Excitedly, he paid the premium without disclosing his three-year history of hypertension.
Fast forward to 2014, Aditya faced severe chest pain, necessitating hospitalization. To his dismay, doctors traced the complication back to worsening hypertension spanning seven years, from 2007 to 2014. Aditya, assuming his policy would cover the treatment costs after the waiting period, found himself in a bind. Unfortunately, since hypertension was a pre-existing condition undisclosed during the policy purchase, his claim faced rejection.
When an individual fails to disclose their pre-existing conditions during the application process, it is considered non-disclosure. This omission can lead to significant consequences, particularly during the claims process. If a claim is made related to a pre-existing condition that was not disclosed, the insurance company may reject the claim. Non-disclosure is often viewed by insurance providers as a breach of trust and a violation of the terms and conditions outlined in the insurance policy.
Policyholders must be transparent and provide accurate information about their health status when applying for insurance coverage. Full disclosure ensures that the insurance company has a comprehensive understanding of the individual's health risks, enabling them to set appropriate terms and conditions for coverage. Failure to disclose pre-existing conditions not only jeopardizes the chances of successful claims but may also lead to the cancellation of the policy in extreme cases.
FAQs
Unfortunately, most health insurance plans cover pre-existing diseases after a waiting period of 2 to 4 years as people are already suffering from such diseases at the time of policy purchase. Thus, they increase the liability of the insurer.
Can you be denied for pre-existing conditions? ›
Under the Affordable Care Act, health insurance companies can't refuse to cover you or charge you more just because you have a “pre-existing condition” — that is, a health problem you had before the date that new health coverage starts.
What if pre-existing conditions are not declared? ›
Failure to disclose pre-existing conditions not only jeopardizes the chances of successful claims but may also lead to the cancellation of the policy in extreme cases.
How long can an insurer exclude coverage for a pre-existing condition? ›
The same goes for individual insurance purchased through a state or the federal health marketplace. Should a non-ACA-compliant plan still exclude pre-existing conditions, in most cases, it can only do so for a certain period—12 or 18 months, depending on when you enrolled.
What is the usual minimum waiting period for a pre-existing condition? ›
Pre-existing conditions exclusion
This type of waiting period can last a maximum of 12 months, unless you're a late enrollee, in which case it can go up to 18 months. It excludes coverage for any conditions that were diagnosed or recommended for treatment in the 6 months prior to your enrollment date.
What is the 6 month waiting period for pre-existing conditions? ›
A pre-existing condition is defined as any ailment, illness, or condition where, in the opinion of a medical adviser appointed by the health insurer, the signs or symptoms of that illness, ailment or condition existed at any time in the period of 6 months ending on the day on which the person became insured under the ...
How do insurance companies determine pre-existing conditions? ›
How are pre-existing conditions determined? A pre-existing condition is typically when you have received treatment or diagnosis before you enrolled in a new health plan.
What counts as a pre-existing condition? ›
A pre-existing medical condition (PEMC) is an illness or injury you had before your policy began or was renewed. Examples of pre-existing medical conditions include, diabetes, asthma, high cholesterol or a long-term back condition.
Why is it OK to deny health coverage to people with preexisting conditions? ›
A pre-existing condition is any illness or condition a patient has prior to obtaining insurance. In the past, people could be barred from getting a health plan because of a pre-existing condition. Thanks to the Affordable Care Act, pre-existing conditions are no longer grounds for refusing to sell someone insurance.
What is a waiver of pre-existing conditions? ›
Simply put, the Waiver of Pre-Existing Medical Conditions covers, or “waives” the companies right to exclude pre-existing medical conditions from their policy. It's a feature only available with certain comprehensive package plans that include trip cancellation/trip interruption.
Don't be tempted to lie about your health on your life insurance application; if your insurer later discovers false information or omissions, you could be disqualified from coverage or, at a minimum, experience a significant premium increase.
Which health insurance company denies the most claims? ›
Claim denial rates by insurance company
| Company | Claim denials |
|---|
| UnitedHealthcare | 32% |
| Anthem | 23% |
| Aetna | 20% |
| CareSource | 20% |
1 more rowMay 15, 2024
Pre-Existing Diseases (PED) Waiting Period
Examples of some pre-existing diseases are thyroid, hypertension, and diabetes. Generally, the waiting period for pre-existing disease in health insurance plans is 1-4 years.
What is the exclusion period for preexisting conditions? ›
The time period during which a health plan won't pay for care relating to a pre-existing condition. Under a job-based plan, this cannot exceed 12 months for a regular enrollee or 18 months for a late-enrollee.
How to avoid pre-existing condition exclusion? ›
If your health plan is fully compliant with the ACA and obtained in either the individual/family market or the employer-sponsored market, you no longer need to worry about pre-existing condition exclusion periods.
How far back is a pre-existing condition? ›
A pre-existing medical condition is a disease, illness or injury for which you have received medication, advice or treatment or had any symptoms (whether the condition has been diagnosed or not) in the five years before your joining date. Health insurance doesn't usually cover 'pre-existing conditions'.
Can you get insurance for pre-existing conditions? ›
Private health insurance is usually available for people with pre-existing conditions, but exclusions will be applied to your policy. You won't normally be able to claim for treating any current conditions or conditions that require ongoing care (chronic conditions).
What is the waiting period in term insurance? ›
After you purchase insurance, there will be a waiting period wherein you can not claim any policy benefits. The duration differs from insurer to insurer, but the usual waiting period is 30 days to 180 days. During this period, if anything happens to you, your insurer won't cover it.
