Selected Benefits, we deal with this question on a daily basis and the answer is quite simple.  A pre-existing condition is defined as any medical condition for which you have been diagnosed or treated within 12 months of the effective date of your policy.  An example of a pre-existing condition would be going to your doctor for a swollen knee 7 months before the your policy started.  Even if you had no physical treatment or rehabilitation suggested by the doctor, the diagnosis alone would be considered a pre-existing condition.

The insurance carrier determines the net result of a pre-existing condition on your policy.  One of the ways the providers will handle the condition is by adding an “exclusion waiver” for the condition and/or the medication taken.  An example of this would be the diagnosis of High Cholesterol.   The provider will cover you for a heart attack or illness due to the diagnosis, but “exclude” the medication you take daily to control your cholesterol.  A competent agent (see Selected Benefits above) should know that some providers will handle the diagnosis in this fashion and some will not.  The alternative is going with a Texas health insurance carrier that does not use exclusion wavers.  These carriers will cover the issue in question as long as it’s been noted on the insurance application.

The final and most important part of the equation is the 63 day gap in coverage clause. This situation is where it gets tricky.  The clause states that you have a 63 day grace period between the ending point of your last policy and the beginning of the new policy. If you do not gain coverage within that period, all of your pre-existing illnesses will be subject to a 12 month waiting period.

It is vital to not exceed the 63 day gap between policies. Depending on the severity of the condition, you could save hundreds to thousands of dollars per year in medical bills by avoiding the gap.  When canceling a policy and moving to another, you must forward the “certificate of credible coverage” on to the next insurance carrier.  This insures that your pre-existing conditions are covered from day one of the new policy.  Since it generally takes 10 days or so to receive the Certificate, any claims adversely affected will be automatically reprocessed once the certificate is received by the new insurance carrier.