Pre-existing medical conditions and health insurance – a guide

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Many New Zealanders take out health insurance policies to give them peace of mind about paying for medical care in the future. However, while they all have different terms your health insurance policy may decline to pay out if your claim relates to a pre-existing medical condition. To avoid future disputes, learn the rules around pre-existing medical conditions. 

Health insurance and your duty to disclose

It is important that you disclose all pre-existing conditions so that your insurer cannot later decline your claim for non-disclosure.

First and foremost, you need to be honest and give complete, up-to-date and relevant information when you are:

  1. Applying for a policy of insurance (“Policy”)
  2. Renewing a Policy
  3. Making a claim
  4. Or if your circumstances change

Steps that you can take to ensure that you are giving appropriate information to your insurer include:

  • Telling your insurer about any new events each time you renew your Policy
  • Answering all of the questions on the application (even if you don’t think they are relevant)
  • Contacting your insurer if you forgot to include something on the application (duty of ongoing disclosure) 
  • Reading through your application carefully before signing 
  • Asking your doctor for a copy of your medical notes if you cannot remember your medical history

What is considered a pre-existing condition for insurance?

We have included some examples of pre-existing conditions below. They include a condition, sign or symptom that:

  • was treated and/or diagnosed before you applied for health insurance 
  • you knew about, regardless of whether or not you decided to seek medical treatment
  • you had previously sought treatment for or asked for medical advice about
  • was identified in a diagnosis or medical screening, even if you did not know about it

Some of the most common examples of pre-existing conditions include cancer, diabetes, depression, acne, pregnancy, sleep apnoea and asthma.

What if I find out about a pre-existing condition after taking out insurance?

Each policy is different, so it is important to check with your insurer. As soon as you find out about the condition, it is best to let your insurer know. There may be a waiting period before you can claim for a pre-existing condition.

What if I have a health condition that I want to be covered?

Often, pre-existing conditions will not be covered by medical insurance. However, in New Zealand some insurers will offer cover that relates to pre-existing conditions:

  • You may be charged an extra premium to cover the condition.
  • You may be provided with cover, after a “stand down” period. For example, an insurer may cover a pre-existing condition after you have been covered by them for a specified period.

Each insurer has a differing approach when it comes to how to approach exclusions. It will depend on your pre-existing condition and what it is associated with. If you have a condition that you would like to be covered by your policy, it is worthwhile looking around and finding a policy/insurer that works best for your needs.

If I have been treated for a condition and I am now in the clear – do I still need to report the condition?

Yes – you should report all pre-existing medical conditions, or provide all relevant medical notes for assessment to the insurer.

Can I dispute what a pre-existing condition is?

If your claim has been declined due to the existence of a pre-existing condition, there are steps that you can take to have the decision reviewed if you disagree with the insurer’s decision.  Contact Shine Lawyers for more information on the best steps forward.

Why choose Shine Lawyers NZ?

Many insurance companies do not pay claims if there is a dispute in regards to cover under the Policy, including when the insurer has declined to pay a claim or to cover a condition on the basis it is a pre-existing condition. When this happens, it is easy for those affected to feel helpless and suffer severe financial and emotional hardship.

At Shine Lawyers NZ, our insurance lawyers are experts in bringing justice when insurance companies may have wrongly declined a claim or retrospectively applied a pre-existing condition to a Policy. 

Our Insurance Law Team always goes above and beyond in what we do, and most importantly, we are not afraid to take on the big insurance companies.

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