What Is a Pre-Existing Condition?

A pre-existing condition is an illness or health condition that was known and existed prior to applying for health or life insurance. Before the introduction of the Affordable Care Act (ACA), health insurance companies could deny coverage or charge you more for pre-existing conditions. In most cases, this is no longer allowed.

Key Takeaways

  • A pre-existing condition is a health condition that existed prior to applying for health or life insurance—such as diabetes, cancer, and heart disease.
  • Under the Affordable Care Act, health insurance companies can’t refuse coverage or charge more if you have a pre-existing condition. An exception is grandfathered individual health insurance policies.
  • It is possible to buy life insurance from some companies if you have a pre-existing condition, but premiums may be higher and death benefits lower.

Understanding Pre-Existing Conditions

Pre-existing conditions include illnesses such as diabetes, cancer, and heart disease—to name a few—and less serious conditions, such as a broken leg, and even prescription drugs. Under the Affordable Care Act, which was signed into law by President Barack Obama in 2010, health insurance companies can’t refuse coverage or charge more just because you have a pre-existing condition. 

The Affordable Care Act also mandates that health insurers cannot limit benefits or, once you have insurance, refuse to cover treatment for a pre-existing condition. These rules went into effect for plans beginning on or after January 1, 2014.

Prior to the Affordable Care Act, also known as Obamacare, health insurance companies would not cover pre-existing conditions until a specified period of time has passed, or in some cases, not cover them at all. No such laws apply to life insurance policies. It's still possible to buy life insurance from some companies if you have a pre-existing condition, although premiums may be higher, death benefits lower, and policies will likely include a waiting period.

The pre-existing coverage rule does not apply to “grandfathered” individual health insurance policies. A grandfathered individual health insurance policy is one that you bought for yourself or your family on or before March 23, 2010, that has not been changed in certain ways that reduce benefits or increase costs to consumers.

Special Considerations

In March 2019, the Trump administration said that it would seek to repeal the entire Affordable Care Act. Rolling back the law was one of Trump's central campaign promises.

In a letter to a federal appeals court, the Justice Department said it agreed with a federal judge in Texas who declared the healthcare law unconstitutional and added that it will support the judgment on appeal. The case is currently with the Supreme Court as of January 2021.

54 million

The number of Americans—or 27% of all adults under 65—that have pre-existing health conditions, according to the Kaiser Family Foundation.

 

In the run-up to the presidential election, Donald Trump signed an executive order in September 2020 deeming that pre-existing conditions protections will stay in place if the Affordable Care Act is repealed. Legal experts maintain that the executive order is not enforceable as it has no authority to regulate the insurance industry.