Pre-existing issue (medical)

Question

I have a sub-dermal haemangioma on the side of my face, its barely visible, and its been there since I was young. We had it looked at by a professional when I was child and it was never officially diagnosed, as it is benign and mostly topical, the doctor said not to mess with it and that it would go away with age. Some 20 years later it began to reemerge and I felt it was time to have it fully diagnosed which is when we determined the above classification a sub-dermal haemangioma.

The insurance paid for the entire diagnosis from MRI to angiogram to determine if it had inter-cranial vessels, however they are refusing to pay for treatment given that they claim it was "pre existing."

"Our medical advisor has emphasized, that the fact that you were not previously in discomfort/pain does not change the fact that the condition was already present since you were 3 years old. Therefore, the condition already existed before you applied for your insurance with us."

According to my insurance provider: A pre-existing condition is a medical condition that has been established prior to the inception date of your insurance coverage. Therefore, wouldn't they have to be able to prove that this was an established issue prior to insurance? There are no official records on my first visit to the physician when I was younger. And sure, this may have been there before I obtained their insurance, however it was unknown to me in that it didn't erupt until after I had insurance. According to my doctor these things can even grow inside you and you wouldn't be the wiser unless you started feeling discomfort.

Answer 1

As they say, a pre-existing condition is one that was existing at the time you applied for and were given insurance.

A pre-existing condition may be known or unknown: insurance will generally cover unknown conditions (e.g. congenital defects, undiagnosed diseases), and this seems to be what they are saying . Known conditions are generally 1) not covered 2) covered if disclosed and accepted or 3) covered after certain waiting times depending on the law in the relevant jurisdiction.

If you took them to court, as a civil matter the case would be proven on the balance of probabilities. That is, based on the evidence, is it more likely or not that the condition was pre-existing. You would put forward evidence that it wasn't and they would put forward evidence that it was. Part of the evidence that they would put forward is swearing you in and asking "Did you have this diagnosed as a child" - you will then either say "Yes" or perjure yourself. If you say "yes" then their case is proved - if you don't then I hope the jail you go to has a good medical clinic.