What is sudden and unexpected recurrence of pre-existing condition?
As the name suggests, if you have a pre-existing condition, and if you had a occurrence of that pre-existing condition in the past (before the effective date of the policy) and if you have a sudden and unexpected recurrence of the pre-existing condition, you may be covered according to the terms and conditions of the policy.
Are all sudden and unexpected recurrence of pre-existing conditions covered?
No.
Even though the exact rules vary by a specific insurance policy, there may be additional restrictions such as
- the person must be stable for at least 30 days prior to effective date with no change in treatment
- the condition must not be chronic or congenital condition
- the condition must not become worse over time
- the person must not be traveling to seek treatment for pre-existing condition
- the person must not be traveling against the advice of the physician or recommended treatment
There may be additional restrictions such as Urinary Tract Infection (UTI) not included for a certain period under this clause and other restrictions. Please look at the details of the specific plan.
If the person never had an occurrence of pre-existing condition, does that mean it would be considered as new condition and covered normally?
Not necessarily.
Pre-existing condition exclusion applies to any medical condition that existed before the effective date of the policy, whether you knew about it or not.
On the other hand, sudden and unexpected recurrence of pre-existing condition applies only if you had a prior occurrence of that pre-existing condition.
Any medical condition would either be a new medical condition or pre-existing condition. Therefore, if a plan has coverage for new medical conditions as well as the sudden and unexpected recurrence of pre-existing conditions, wouldn't that person be covered either way?
Not necessarily. Even if the person didn't know about the medical condition, but if it existed prior to the effective date of the policy, it could be a pre-existing condition and excluded. On the other hand, if the person didn't have an occurrence of a specific pre-existing condition before the effective date of the policy, that would not be a recurrence of pre-existing condition. Therefore, it could be excluded under that clause as well.
That does not make any sense to me. Can I get some actual examples of the circumstances where people were actually covered or declined under this clause?
Example: Let's say the person was treated for a kidney stone while the insurance was effective.
The first clause is the Sudden and Unexpected Recurrence Provision.
In order to be eligible for this provision a person must have received prior treatment for a known kidney stone. If the person did not have prior treatment for a known occurrence of a kidney stone, this is not a recurrence. If something has not happened before, it cannot be a recurrence.
The second clause is Pre-Existing Condition.
Even if the insured did not have symptoms of her kidney stone until after her effective date of coverage, it is a condition, that with reasonable medical certainty, existed at the time of the Application.
In short, if the insured's kidney stone existed before the effective date of coverage, which makes it a Pre-existing Condition, and there has been no prior treatment for an occurrence of a known kidney stone, it does not meet the requirements of the Sudden and Unexpected Recurrence Provision.
That means, it is excluded under both clauses.
Please do NOT assume that all of the claims would be paid/declined exactly as described in representative examples or scenarios. Your specific scenario and the decision about the claim can only be determined after-the-fact when the insurance company's claims department has all the medical records including the attending physician statement.
In order for a heart attack to be covered under that clause, is it a pre-requisite that the person must have had a prior heart attack before the effective date of the current policy?
A heart attack is not a pre-existing condition, but instead is most often an acute manifestation of the underlying medical condition of coronary artery atherosclerosis (CAD) (Please note that there are some rare causes of heart attacks that are not caused by CAD, e.g., Takotsubo Cardiomyopathy, Prinzmetal Angina, etc., but the examples here deal with CAD as the primary cause of heart attacks.) If someone had a pre-existing diagnosis of CAD, she/he could have had symptoms or manifestations of CAD without having had a prior heart attack - e.g., chest pain diagnosed as Coronary Angina, stent placed in a blocked artery, or the discovery of CAD on routine physical leading to medical or surgical intervention. If the same person had that condition stabilized then suffered a heart attack after their Effective Date, that would be considered a sudden recurrence of the pre-existing condition.
According to the above explanation, CAD is the pre-existing condition. If the person never had a CAD diagnosis/treatment prior, it would not be covered under sudden and unexpected recurrence of pre-existing condition. On the other hand, if the person never knew about his/her CAD, and didn't have any treatment for the same, it would still be declined under pre-existing conditions clause, because it existed/manifested earlier.
Similarly, if the person had a blood pressure or diabetes or cholesterol, that could possibly be related to the heart attack the person might have and excluded that under pre-existing condition clause as well. That seems contradictory. If CAD really is pre-existing condition, why would heart attack coverage be declined just because person had blood pressure or diabetes or cholesterol? We have no answer for that.
In order for stroke to be covered under that clause, is it a pre-requisite that the person must have had a prior stroke before the effective date of the current policy?
The underlying medical conditions leading to a stroke are cerebrovascular atherosclerosis, embolism (clots) from extra-cranial atherosclerotic disease like Carotid Atherosclerosis, or embolism from the heart in patients with Atrial Fibrillation. A stroke that occurred after Effective Date, with previous documented history or manifestations or symptoms of the stabilized conditions of cerebrovascular atherosclerosis, Carotid Occlusive Disease or Atrial fibrillation would be a sudden recurrence of that particular pre-existing condition.
In order for brain hemorrhage to be covered under that clause, is it a pre-requisite that the person must have had a prior brain hemorrhage before the effective date of the current policy?
A brain hemorrhage also has many causes (underlying medical conditions), and as with the above, it is the underlying medical condition that is considered. If someone with a previous history of hypertension has a hypertensive brain hemorrhage after Effective Date, that would be a sudden recurrence of that pre-existing condition. If they have a known and stabilized cerebral aneurysm which then bleeds after Effective Date, that would be a sudden recurrence of that pre-existing condition. If they have known cerebrovascular atherosclerosis (or any of the conditions in the above paragraph) and suffer a hemorrhagic stroke (rather than an ischemic stroke) after Effective Date, that would be a sudden recurrence of that particular pre-existing condition.
What exactly is covered?
As the request for generic examples (obviously without revealing Private Health Information (PHI) of specific insureds) of the actual claims paid/denied was declined by the insurance company, it is difficult to answer that. It seems that this clause of 'sudden and unexpected recurrence of pre-existing condition' provides coverage possibly in some very narrow set of circumstances, if any.
What is the difference between 'Acute onset of pre-existing condition' coverage versus 'sudden and unexpected recurrence of pre-existing condition' coverage?
Acute onset of pre-existing condition coverage provides a lot broader coverage under a lot more scenarios compared to sudden and unexpected recurrence of pre-existing conditions coverage. Read more about Acute Onset of Pre-Existing Conditions FAQ in the article below.
Even though the examples below may not apply to everyone as everyone's specific situation is different, we can give provide a scenario that may give you an idea about how the claims may be processed under these two types:
Acute Onset of Pre-Existing Condition: A person had a heart attack all of sudden for the first time and was rushed to an emergency immediately. The person had a history of high blood pressure but no other heart related diagnosis or treatment. This claim was paid.
Sudden and Unexpected Recurrence of Pre-Existing Condition: A person has a heart attack for the first time. If the person has had no treatment done earlier or had no heart attacks earlier (no occurrence earlier), it would not be considered sudden and unexpected recurrence of pre-existing condition and the claim would be denied. At the same time, if it is determined that the person had a heart disease before the effective date of the policy, it would be denied under pre-existing conditions clause as well.
Again, please do NOT assume that all of the claims would be paid/declined exactly as described above. This is just one representative example. Your specific scenario and the decision about the claim can only be determined after-the-fact when the insurance company's claims department has all the medical records including the attending physician statement.
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