Symptoms Count When Defining Pre-existing Conditions
By Milan Korcok, Health Issues Writer
Recently a senior Canadian traveller crossed into the United States at a highway border point and within an hour was forced to check into hospital complaining of weakness, dizziness, profuse sweating, nausea, and faintness. In the emergency room, the man's wife told the admitting doctor that her husband had only experienced these symptoms "off and on" for a few weeks prior to their trip, and had also, recently, passed a few black stools. But other than that he had a clean medical record. The diagnosis was quick and easily made - a bleeding ulcer, otherwise known as an upper gastrointestinal bleed. All of the classical symptoms were in place and had been for some time. The patient was relatively quickly treated, the bleeding stopped, and in a few days he was permitted to continue on his trip. But when it came time to claim for the hospital emergency, the traveller ran into a problem when his insurer denied the claim on the grounds that the man clearly had a pre-existing medical condition when he bought his travel health insurance. His broker objected and said that prior to his trip the man had never been diagnosed with a GI bleed, and unless his own Canadian doctor had recorded such a specific condition on his record, the claim could not be denied.
Well, that may have been his interpretation of a pre-existing medical condition, but it's rarely the way pre-ex's are defined in policy language. And that's the governing authority - not some dictionary or random definition found elsewhere. In this case the definition of pre-existing medical condition was clearly stated as: "any symptoms or signs of an illness or disease known to the insured prior to ....." the effective date of coverage. What matters is that the client was suffering significant abnormal symptoms prior to the purchase of the policy, and they worsened and resulted in his hospitalization. As the medical director in this case noted: "I cannot accept the argument that there must be a documented visit to a physician and a confirmed diagnosis established before benefits can be denied." No doubt about that, according to the policy wording. Symptoms matter. They are part of the illness. And that's important for brokers to emphasize to their clients - especially those who have some medical abnormalities, even ones that do not have clear-cut technical names attached to them.
Article provided compliments of Trent Health. Author Milan Korcok is a freelance medical writer specializing in travel health issues. May not be reproduced or transmitted without permission.