What counts as a pre-existing condition?

At a glance#

Why pre-existing conditions are the usual dispute#

Of all the clauses in a travel policy, the pre-existing condition exclusion decides the most and is read the least. It rarely appears in marketing copy, it always appears in the certificate, and it separates the policies that do something for a particular traveller from the ones that are effectively worthless to them.

Travel policies are seldom bought for the premium and almost always for a specific risk. That risk is frequently an existing condition, which is the one thing the certificate excludes.

The logic is the logic of insurance. What is insured is the uncertain, and a known condition is a foreseeable one. The look-back period follows from that: everything treated or diagnosed inside it counts as foreseeable, and everything arising after purchase counts as chance.

Nothing is usually asked at purchase. The review happens at claim time, when the medical history is on the table, generally through an authorisation to release records. Refusing that authorisation means no payment, while granting it for an entire medical history opens more than necessary. An authorisation limited to the claim is the usual middle ground.

There is a statistical reason for the strictness as well. Trips are cancelled for illness more than for anything else, and a large share of those cancellations involve people who were already ill. Without the exclusion the premium would be noticeably higher for everyone.

So the search is not for a policy without the exclusion but for one with a waiver. Those are two entirely different products, and only the second one helps.

How the exclusion is written#

The typical elements#

The exclusion is built from a look-back period, a description of what counts as treatment, and a purchase date from which both are measured. Excluded as a rule are conditions treated, tested, diagnosed or newly medicated within the defined period before the policy was bought. On top of that there is almost always an exclusion for treatment already planned at departure: travelling in order to receive treatment is not insured for that treatment.

The length of the look-back period is the most important number in the whole contract, because it decides whether a condition stable for years still counts as pre-existing. It is also the easiest point of comparison between offers. It appears as a number, it is not open to interpretation, and it says more about the value of a policy than any schedule of benefits.

Judging a policy by its benefit limits alone is the opposite habit and a costly one. A high limit with a broad exclusion pays less than a lower limit with the right waiver, and comparison sites usually sort by the wrong one of the two.

The wording varies considerably from insurer to insurer. Some certificates say treated, others say a change in medication, and the difference decides cases where someone has taken the same prescription for years without seeing a doctor.

What stays covered#

Whatever arises newly and independently stays covered. A broken leg on holiday has nothing to do with an existing heart condition, and anything first diagnosed after purchase is covered as well, because the purchase date works in both directions.

Acute emergency treatment frequently stays covered too, even for a known condition. That point differs sharply between trip cancellation and emergency medical coverage, as travel medical insurance describes.

Trips with a medical escort are a case of their own. Someone travelling for treatment with a companion insures two people with different risks on one trip, and the companion is normally covered in the usual way. Cover for a family member who stays at home deserves a look as well; travelling with older relatives, or leaving someone behind, makes that clause the decisive one. The same pre-existing rules apply to that relative, which surprises most claimants.

Cancelling out of fear that a condition may worsen is not covered almost anywhere. The policy insures the event, not the worry about it, and that line is drawn equally firmly everywhere.

The waiver and the purchase window#

The waiver is the mechanism that switches the exclusion off. It is granted when the policy is bought inside a short window after the first payment towards the trip, and two further conditions usually apply: the whole non-refundable trip cost has to be insured, and the traveller has to be fit to travel on the day of purchase.

Missing the window removes the option, and no later purchase brings it back. The policy is therefore bought on the day the trip is booked. On trips booked far in advance the timing matters even more, since a trip booked a year ahead carries a year of medical history that has yet to happen, and the waiver keeps all of it inside the coverage.

A traveller who has already missed the window still has one way back. Rebooking the trip creates a new first payment, and on a freely cancellable booking that step costs nothing but a little effort.

Travellers who take several trips a year compare an annual policy with single-trip cover on more than price. The early start date of an annual policy is its real advantage with an existing condition, and it works for every trip of the year.

The order of decisions follows from all this. When an existing condition is the main risk, the policy comes first and the trip second. In that order a plan with a waiver can be chosen; in the reverse order only a standard plan remains.

Worked example: a trip with a known condition#

The example is a booked trip and a chronic condition that has existed for years and is well controlled.

Nearly every dispute turns on the worsening of the known condition. How the policy treats it decides whether the policy is worth buying for this traveller at all.

Emergency treatment of the known condition is what should drive the choice. A policy that covers it is worth far more to someone with a chronic illness than a lower premium.

The routine check-up surprises people. A check-up planned anyway at the destination is not unforeseen treatment, and it is not reimbursed even when it is medically necessary, as travel medical insurance describes.

An accident is the least contested case. It is independent of any medical history, the policy pays without argument, and for travellers with chronic conditions it frequently remains the only claim of practical relevance.

To apply the table to a specific situation, put the actual condition in place of the worsening and read the matching exclusion in the certificate. After that it is settled whether the policy does anything at all for that case.

The physician’s statement#

A statement of fitness to travel as of the purchase date is a strong document, because it describes the state of health at the moment that matters. It is best issued close to the purchase date. A statement written after the claim carries less weight.

A physician’s letter does not replace a waiver, and where the policy excludes the condition a letter changes nothing. Its value lies in the boundary cases. Whether a worsening was foreseeable is a medical question, and the answer comes from the treating physician.

Where a medical questionnaire is used for an upgraded policy, the same care applies as with any insurance application. Answering incompletely risks forfeiting coverage entirely, which is worse than having no waiver at all.

When it is not worth buying#

Trip cancellation coverage does little in the following cases:

• When the known condition is the entire risk and no waiver was obtained. The policy then excludes the one risk that matters.
• On very cheap trips. The premium bears no relation to the trip cost.
• On freely cancellable bookings. Where the booking can be undone without cost, there is nothing to insure against cancellation, and only the medical side of the coverage remains relevant, as free cancellation describes.
• When the policy is bought shortly before departure. The purchase date then excludes almost everything.
• When a card already covers the trip. The terms of that cover come first, as credit card travel insurance describes. The same exclusions apply there, often worded more tightly, and card policies rarely offer a waiver.
• On trips booked at short notice. Booking a few days before departure leaves little time for an illness to arise beforehand, so emergency medical coverage matters more than cancellation coverage.

A traveller in good health has no use for the whole waiver question and is well served by a standard plan.

What to do about a denial#

Much of a dispute is decided before it starts. The insurer is notified before the trip is cancelled, not after, because the reverse order regularly results in cancellation costs being recognised that would have been lower with earlier notice.

After a denial, the reason is requested in writing and compared against the wording of the certificate. Exclusions tend to be applied more broadly than they are written.

A statement from the treating physician on foreseeability helps, since that is the point on which many cases turn. Asking which purchase date the insurer used helps too. The wrong date is a common and easily corrected error.

Partial settlement is worth raising as well. Many insurers will cover the cancellation costs that would have arisen regardless of the condition, and nobody offers that unprompted.

The most common mistakes#

• Buying weeks after booking. The waiver window is short and opens with the first payment, so the policy belongs to the same day.
• Treating the exclusion as a formality. It is the most common reason for a denial.
• Buying without checking the look-back period. That one number decides the case.
• Relying on a physician’s letter. A letter helps at the boundary and does nothing against a clear exclusion.
• Accepting a denial. The written reason, set against the wording of the certificate, is where an objection starts.
• Insuring twice. Existing cover, from a card or elsewhere, gets checked before anything new is bought.

Related topics#

• Travel medical insurance
• Credit card travel insurance
• Free cancellation
• A flight you did not take
• Reading fare rules
• Chargeback