We use cookies to improve security, personalize the user experience,
enhance our marketing activities (including cooperating with our marketing partners) and for other
business use.
Click "here" to read our Cookie Policy.
By clicking "Accept" you agree to the use of cookies. Read less
Understanding Preexisting Condition Exclusion [Internal Revenue]: What You Need to Know
Definition & Meaning
A preexisting condition exclusion refers to a restriction or denial of health benefits based on a medical condition that existed before an individual's health insurance coverage began. This means that if a person had a health issue prior to their coverage start date, the insurance provider may limit or deny benefits related to that condition. This exclusion applies to both group health plans and individual health insurance policies.
Table of content
Legal Use & context
This term is commonly used in the context of health insurance and employee benefits law. It is particularly relevant in civil law, where individuals may seek to understand their rights regarding health coverage. Users can manage related forms and procedures using templates from US Legal Forms, which are drafted by qualified attorneys to ensure compliance with applicable laws.
Key legal elements
Real-world examples
Here are a couple of examples of abatement:
Example 1: A person diagnosed with diabetes before enrolling in a new health insurance plan may find that their insurance provider excludes coverage for diabetes-related treatments.
Example 2: An individual who had a knee injury prior to obtaining health insurance might face limitations on coverage for knee surgery under their new plan. (hypothetical example)
State-by-state differences
State
Preexisting Condition Exclusion Rules
California
Strict regulations limit preexisting condition exclusions for individual plans.
Texas
Allows preexisting condition exclusions but requires disclosure in policy documents.
New York
Prohibits preexisting condition exclusions in most health insurance policies.
This is not a complete list. State laws vary, and users should consult local rules for specific guidance.
Comparison with related terms
Term
Definition
Difference
Exclusion
A general term for any limitation on coverage.
Preexisting condition exclusions are specific to conditions present before coverage.
Waiting Period
A set time before coverage begins for certain conditions.
Waiting periods apply to all conditions, while preexisting exclusions apply only to previously existing conditions.
Common misunderstandings
What to do if this term applies to you
If you find yourself facing a preexisting condition exclusion, review your health insurance policy to understand your rights. Consider the following steps:
Contact your insurance provider for clarification on the exclusion.
Explore options for different plans that may not impose such exclusions.
Utilize US Legal Forms for templates to appeal a denial or to seek legal advice.
If the situation is complex, consult a legal professional for tailored guidance.
Find the legal form that fits your case
Browse our library of 85,000+ state-specific legal templates.