Health Insurance Claim Articles

Post-Application Manifestation Of A "Pre-Existing" Health Condition: No, You
Are Not Necessarily Up The Creek Without A Paddle As The Carrier
May Be Suggesting

By Jeffrey L. Greyber, Esq.

Here is the hypothetical, yet all-too-common real life, scenario around which this blog revolves: you represent to a disability or life insurance company during the insurance application process that you do not have any noteworthy pre-existing conditions, but you find out for the first time after inception of your coverage that you had a malignant tumor growing in you at the time of application. What, then, if your once unknown condition renders you unable to work or, God forbid, results in your passing away? Are you (or your beneficiary) precluded from receiving indemnification under your disability or life insurance policy because your condition technically “pre-existed” policy inception? Thankfully, the general answer is that the carrier cannot avoid coverage under such a circumstance:

As a general rule, a sickness or disease originates when it becomes manifest or active, or when there are sufficient symptoms to allow a medical practitioner to diagnose the condition with reasonable accuracy. Thus, a sickness may not be ‘manifest’ within the meaning of the exclusion though latent germs or infection are present in insured'[s] body. However, there is some authority which holds that a sickness can exist even before there is any outward manifestation of it. The general rule requiring outward manifestation or symptoms of diagnostic significance serves the dual function of protecting the insurer against applicants who are aware of, but fail to disclose, a preexisting illness or disease, while protecting innocent insureds from being deprived of coverage for unknown preexisting conditions.^{1 2}

As noted, most jurisdictions prescribe to this well-reasoned general rule. But, that said, application of the general rule is often case-by-case and fact-intensive. So, if confronted with an insurer’s attempt to deny coverage based on a “pre-existing” condition when, in actuality, you had no knowledge of the subject condition until after coverage began, please do not just roll over … instead, talk with an experienced policyholder attorney regarding whether the above general rule should apply to your facts.

¹ 10A Couch on Ins. § 144:88 (West, June 2013) (internal citations omitted).
² An insured faced with a carrier’s “pre-existing” claim denial may also be able to refute the denial by, among other things, a policy’s incontestability provision. Incontestability provisions will be the subject of a future blog.

Health Insurance Claim Articles