What is a pre-existing condition?

What is a pre‑existing condition?

A pre‑existing condition refers to any illness or ailment that you’ve already had BEFORE the start of your private health insurance plan.

Many health insurance companies won’t cover pre-existing conditions, or have lots of rules around them, so it’s really important to understand what does and doesn’t count as ‘pre-existing’ – and what you’re actually covered for.

What counts as a pre-existing condition?

A pre-existing condition is any disease, illness or injury that you have symptoms of or received medication, advice or treatment for, usually in a set period before the start of your plan.

It includes conditions that have been officially diagnosed, reoccurring conditions even if you’ve had no symptoms for a while, and conditions that haven’t been diagnosed but that you could be reasonably assumed to know about – even if you didn’t actually speak to a medical professional.

What are some examples of pre-existing conditions?

Imagine you had a dodgy knee. Maybe you saw your GP and got a prescription for some painkillers. Maybe you saw a physiotherapist, or even had knee surgery to fix the problem. Maybe you just had symptoms and self-managed it with medication or exercise. If the same knee starts playing up again, it WON’T be covered by your private health insurance.

Perhaps you’ve already had a health insurance plan for (say) a year. You recently saw your GP about heart pains and you’ve been having those pains on/off for few years. Your GP would like to refer you to a heart specialist. This would be excluded as pre-existing because of the pain symptoms existing for some time before the cover was taken out. While the private treatment would not be covered, there may be other GP, helpline or support services that you can still access under your plan.

What are Equipsme’s rules on pre-existing conditions?

At Equipsme, we have an exclusion of three year pre-existing conditions, which means we won’t pay for any condition if you’ve had symptoms, medical advice or treatment for it in the three years BEFORE you became an Equipsme member.

What happens if you book your own treatment without checking first and it’s for a pre-existing condition?

If you don’t check and pre-authorise your claim with the insurance company first, you run the risk that they won’t cover you, or pay out for your treatment. That could leave you with a big bill you weren’t expecting to pay.

Do insurance companies check if you’ve had a pre-existing condition?

Yes. Insurance firms may ask your GP or consultant for more information to confirm whether they can actually cover your claim. If they need to ask about your medical history, it may take a bit of time before you know if they’ll be able to cover your claim. Some GPs/specialists may charge to provide this information, which you will have to pay for.

Why do insurance firms exclude pre-existing conditions?

It’s the same principal as “unforeseen risk” under any insurance. For instance, you wouldn’t expect an insurance company to insure your house if it was ALREADY on fire. That’s not how insurance works.

The whole idea is that lots of people put a little bit of money into a pot. If something goes wrong, they’ve bought the promise from the insurance company that in certain circumstances (ie, the terms and conditions of the insurance) the damage or loss will be put back to as close a position as it was before – even if that means the insurance pays out MORE than they put in. The insurance company balances the books – betting lots of people will put in and only a few will take out. If lots of people take out lots of money the whole system falls down. So the insurance company makes decisions about what is and isn’t a good bet. And insuring a burning house is going to lose them a lot of money... The only way to cover those losses would be to put prices up for everyone.

By excluding things like pre-existing conditions, insurance firms can control costs more closely, and help keep their general prices down so they’re actually more affordable.

I’m not sure if what I’ve got counts as pre-existing! What do I do?

If you’re not sure, ASK!

It’s always a good idea to check in with any health insurer BEFORE you go ahead with any treatment, to make sure they’re going to be able to cover you. Call them up, talk them through what your GP or consultant has said, and ask for confirmation whether they’ll cover you.

How do I find out more about Equipsme and pre-existing conditions?

You can check out our handbook, which you’ll find on your Equipsme members portal, or read our exclusions page online.