Pre-existing Medical Conditions & Duty of Disclosure

This page is designed to give an oversight of two key areas involved in the process of obtaining Private Medical Insurance coverage for Expatriates - the effect of pre-existing medical conditions on an application for cover, and the possible results of not disclosing important medical information to an insurer or plan provider.

Pre-existing Medical Conditions

As to whether pre-existing medical conditions would be covered under a new plan, this will very much depend on the nature of the condition, how long you have had it, what treatment you have had or are still having and other factors which may need to be taken into account.

With regards to  how an insurer will treat cover for any pre-existing condition, this will be directly influenced by the type of underwriting employed by an insurer or plan provider.  This is either on a "Full Medical Underwriting " or a "Moratorium" basis.

Full Medical Underwriting

Where an insurance plan is "Fully Medically Underwritten", medical history is disclosed on the application form.  This is then assessed upon submission to the insurer, by that insurer's underwriters on a case by case basis.

Once assessed, one of a number of outcomes may result:

• The application is accepted without exclusions
• The application is accepted, but with exclusions on pre-existing conditions (either permanent or for a set period of time, which may be reviewable in the future)
• The application is accepted, but with an increased premium applied (known as a "loading") to cover the pre-existing condition
• The application is declined

Under this system of underwriting it is impossible to give a 100% accurate assessment of the effect a pre-existing condition may have on an application for cover without actually submitting an application - as everyone's individual circumstances are different, a case by case approach is necessary.  It is an unfortunate fact, however, that the more serious and/or long term a condition is, the less chance there is of having it covered by a new medical insurance plan.

Moratorium Underwriting

A Moratorium is a waiting period that must elapse before claims for pre-existing conditions may become eligible under a new Private Medical Insurance plan.

Whilst an application form for this type of underwriting may not ask for any medical information to be disclosed, there are specific rules and conditions that must be met before pre-existing conditions would be considered for cover.  Below you will find some examples of these wordings which demonstrate exactly how Moratorium Underwriting operates:

Medicare

A pre-existing condition is any known medical condition (or related condition) that has, within a two year period immediately prior to the commencement of the policy one or more of the following characteristics;

It has been diagnosed.

It has needed medical treatment (including drugs, special diets, injections or other procedures or investigations).

Medical advice has been sort including routine medical examinations.

Medical advice should have been sort if recognized clinical advice had been followed.

It has undiagnosed symptoms, whether recognised or not.

After two years of continuous cover, pre-existing conditions will become eligible for cover (unless the condition or benefit is specifically excluded) if, at the first time of receiving treatment the insured person has not:

Suffered any symptoms.

Consulted any medical practitioner for check ups, follow up examinations, medical treatment or advice.

Been prescribed or taken medicine including over the counter drugs, special diets, injections, physiotherapy for that medical condition or any related condition for a continous two years.

ExpaCare

Pre-existing conditions are excluded from cover under a moratorium (delay period). A pre-existing condition is any known medical condition (or related condition) that has, in the two years immediately before your enrolment date, or the enrolment date of a dependant, one or more of the following characteristics:

- it has been diagnosed.

- it has needed medical treatment (including drugs, special diets and injections).

- medical advice has been asked for, including check-ups.

- medical advice should have been asked for if recognised clinical advice had been followed.

- it has undiagnosed symptoms, whether recognised or not.

After two years of continuous cover pre-existing conditions will become eligible for benefit (unless the condition or the benefit is specifically excluded - see ‘Exclusions: what is not covered’) if, at the first time of receiving treatment, the insured person has not:

- suffered any symptoms;

- consulted any physician for check-ups, medical treatment or advice;

or

- taken any medication (including drugs, special diets and injections) for that medical condition, or any related condition, for a continuous period of two years.

Under the "Moratorium" system of underwriting, it may well be that pre-existing medical conditions may never be covered but cover could still be given for new and unrelated illnesses and diseases.

Duty of Disclosure

You must disclose to insurers/plan providers, before an insurance contract is concluded, any fact or circumstance which is known to you (or which ought to be known to you) which may affect the terms of your policy.

It is especially important to disclose any Pre-existing Medical Conditions, where required, on an application form.  Non-disclosure of required information may lead to a future claim being denied or the cancellation or invalidation of your Private Medical Insurance policy.

Important Note

This document is intended as a "quick reference" guide to Pre-existing Medical Conditions and Duty of Disclosure, and is not a full and comprehensive guide to policy benefits and limits. Full details of coverage provided by each Insurer / Plan Provider are contained within their plan rules and/or policy wordings, which are available upon request.

Andrew Wilson
Sales and Business Development Director

Medibroker Limited
28th June 2006