A pre-existing condition, also called a pre-existing illness, is any condition an individual has before they sign up for health insurance.
Some pre-existing illnesses are chronic or last for a long time. For health policy purposes, pregnancy can sometimes be seen as pre-existing.
Insurance companies and healthcare providers often deny people with pre-existing illness coverage or charge more money.
This is because people who already have health problems cost more to cover and need more health insurance. Because of this, people with these conditions often need coverage the most but have a harder time getting it.
Before the Affordable Care Act, also called “Obamacare,” people with pre-existing conditions could be turned down for insurance or have their coverage changed.
What Are Pre Existing Condition Laws?
Under pre-existing condition laws, health insurers can no longer charge you or your child more or refuse to cover you because of asthma, diabetes, cancer, or pregnancy that you or your child had before. They also can’t put a cap on benefits for this condition.
Once you have insurance, they can’t refuse to pay for treatment for a condition that was there before you got insurance.
What Are Common Pre-Existing Medical Conditions?
There are a number of pre-existing conditions.
The following pre-existing conditions might used to keep people from getting health insurance before Obamacare:
- Diabetes
- Epilepsy
- Hemophilia
- Pregnancy
- Cerebral palsy
- Severe obesity
- Cancer that was diagnosed recently
- Muscular dystrophy
- Rheumatoid arthritis
- Fibromyalgia
- Multiple Sclerosis
- Alzheimer’s disease
- Mental illness
- Alcohol/drug abuse that was treated recently
- Lupus
- HIV/AIDS
What Is Pre-Existing Illness Discrimination?
Pre-existing condition discrimination happens when a person is turned down for health insurance because of a condition they had before they applied for coverage.
Before the ACA went into effect, it was normal for insurers to turn people like this down for coverage. Because of this, the person gets worse medical treatment and has to pay more money out of their own pockets.
A pre-existing condition lawyer can file a lawsuit on your behalf if you believe your insurance provider is denying you coverage based on a pre-existing illness.
Can My Insurance Company Deny Coverage Based on My Pre-Existing Illness?
Even though there have been many votes on whether or not to get rid of it, the ACA is still in place and is still the law of the land regarding health insurance.
Until or unless the ACA is reformed or changed, insurance companies can’t deny coverage for a pre-existing condition. So, if your insurer won’t treat or cover you because of a condition you already had, you should file appeals as soon as possible.
You should use all of your administrative options to show that you attempted to solve your problem without going to court.
Now that discrimination based on a person’s pre-existing condition is against the law, many healthcare institutions attempt to avoid the extra costs of covering people with pre-existing illnesses. This can lead to unfair insurance practices.
For instance, instead of directly rejecting an applicant, a healthcare provider can make specific services more costly than usual to dissuade the applicant from going to them for care. In addition, some insurers may not cover necessary medications, so the policyholder would have to pay for them himself (this can get prohibitively costly).
Not only are these things immoral, but they may also be scams.
If your insurer still doesn’t cover you, get help from a good lawyer.
What’s Happening with the Affordable Care Act?
In California v. Texas, which happened in June 2021, the Supreme Court upheld Obamacare for the third time.
The main parts of the Affordable Care Act went into effect in 2014.
By 2016, the number of uninsured people had dropped by about half, and 20 to 24 million more people were covered, according to estimates.
The law also made many changes to how health care is given that are meant to keep costs down and improve quality. After it went into effect, overall healthcare spending, including premiums for employer-based plans, went up less quickly.
About the same number of people became eligible for Medicaid, and there were also changes to the markets for individual insurance. Both got more money from a mix of new taxes and cuts to Medicare Advantage and Medicare provider rates.
Several reports from the Congressional Budget Office (CBO) said that overall, these provisions cut the budget deficit and that getting rid of the Affordable Care Act would make the deficit bigger and that the law reduced income inequality by mostly taxing the top 1% to pay for benefits of about $600 per family for the bottom 40% of earners.
The act mostly kept Medicare, Medicaid, and the employer market the same, but the individual markets were completely changed.
Insurers were forced to take all applicants and not charge more based on pre-existing conditions or other factors (except age).
To fix this problem, the act required people to buy health insurance (or pay a fine/tax) and insurance companies to cover a list of “essential health benefits.”
Before and after it was passed, the Affordable Care Act was met with strong political opposition, calls to get rid of it, and legal challenges.
The Supreme Court said that states could opt out of the Medicaid expansion part of the law, but the law as a whole was upheld.
HealthCare.gov, the federal health insurance exchange, had a rough start in 2013 because of technical problems.
At first, polls showed that most Americans were against the act, even though most of its parts were more popular.
What Is the Individual Mandate?
Under the “individual mandate,” everyone had to get insurance or pay a fine. The mandate’s goal and the limits on open enrollment were to avoid the insurance death spiral, reduce the problem of “free riders,” and keep the healthcare system from falling victim to “adverse selection.”
The goal of the mandate was to increase the size and diversity of the insured population by getting more young, healthy people to join so that the risk pool would be bigger and the costs would be spread out.
The individual mandate did not apply to the following groups:
- About a third of the estimated 23 million illegal immigrants, or about 8 million people, are not eligible for insurance subsidies or Medicaid. They can still get help in an emergency.
- People who are eligible for Medicaid but are not on Medicaid.
- People whose insurance costs more than 8% of their household income.
- People who live in states that choose not to take part in the Medicaid expansion and who don’t qualify for either the Medicaid coverage they already have or the subsidized coverage.
Starting in 2019, the Tax Cuts and Jobs Act of 2017 cut the fine/tax for not following the individual mandate to $0.
Should I Seek Help from an Insurance Attorney?
If you think you were wrongly turned down for health insurance, an insurance lawyer can help you in many ways. Talk to a qualified insurance lawyer if you don’t have enough coverage or were wrongfully denied coverage. Use LegalMatch to find a lawyer near you today.
