Coverage for Chronic Conditions Under Acute Onset of Pre-Existing Conditions in Visitors Insurance

Every year, hundreds of thousands of people invite their elderly relatives to visit them in the USA. Many of these visitors suffer from one or more chronic medical conditions such as blood pressure, diabetes, heart disease, kidney disease, or other conditions. A chronic condition is a condition that persists for a long time or is constantly reoccurring/recurring.

Most visitors insurance plans are not designed to cover routine maintenance related to chronic medical conditions. Instead, some plans provide acute onset of pre-existing conditions coverage, which is meant to cover sudden and unexpected occurrence of a pre-existing condition that rapidly occurs and requires a reasonable person to seek medical treatment within 24 hours.

The exact definition wording used may vary a bit in the different insurance plans; however, the overall intent and the coverage provided is very similar in all visitors insurance plans.

We had a customer who called our office that happened to have read the certificate wordings of various visitors insurance plans in fine detail. He was particularly interested in a plan from Another Company because of the difference in wording used to explain the Acute Onset of Pre-Existing condition, as it is a little different in these plans compared to similar plans from other companies.

For example, the wording from Another Company and WorldTrips are listed below:

Another Company

Acute Onset of Pre-Existing Conditions(s): Sudden and unexpected outbreak or recurrence of a Pre-Existing Condition(s) that occurs spontaneously and without advance warning either in the form Physician recommendations or symptoms and requires urgent care. The Acute Onset of a Pre-Existing Condition(s) must occur after the Effective Date of Coverage and prior to the age shown in the Schedule of Benefits. Treatment must be obtained within twenty-four (24) hours of the sudden and unexpected outbreak or recurrence. A Pre-Existing Condition that is Congenital or that gradually becomes worse over time is not Acute Onset of a Pre-Existing Condition. A Pre-Existing Condition will not be considered an Acute Onset of a Pre-Existing Condition(s) if, during the thirty (30) days prior to the acute event, You had a change in prescription or Treatment for a diagnosis related to the acute event. This benefit does not include coverage for known, scheduled, required, or expected medical care, drugs, or Treatments existent or necessary prior to arrival in the United States and prior to the Effective Date of Coverage.

WorldTrips

Acute Onset of Pre-existing Conditions means a sudden and unexpected outbreak or recurrence of a pre-existing condition(s) which occurs spontaneously and without advance warning either in the form of a physician recommendation or symptoms, is of short duration, is rapidly progressive, and requires urgent care. The Acute Onset of a Pre-existing Condition(s) must occur after the certificate effective date. Treatment must be obtained within 24 hours of the sudden and unexpected outbreak or recurrence. A pre-existing condition that is a chronic or congenital condition, or a complication or consequence of a chronic or congenital condition, or a condition that gradually becomes worse over time will not be considered Acute Onset. This benefit does not include coverage for known, scheduled, required, or expected medical care, drugs or treatments existent or necessary prior to the certificate effective date.

If you look closely, the Another Company definition says '… that is Congenital or that gradually…' while WorldTrips definition says '… chronic or congenital condition or that gradually…' As you can see, the WorldTrips (for example) wording has the word 'chronic' in it while Another Company does not. ( IMG and Trawick International also has the word 'chronic' in their definition.)

The questions our customer raised, "What additional coverage would he get with Another Company's plans because of the lack of the word 'chronic' that he would not get anywhere else? What kind of chronic conditions are covered in the plans? Could you please provide several examples of the kind of coverages included under 'chronic' conditions?

For example:

• Would you cover kidney dialysis that is needed 3 times a week?
• What about the insulin injections for diabetes?
• Doctor checkup and the prescription medications for the blood pressure?
• Anything else?

Another Company's Response:

I cannot speak for our competitors or their intent but I do know that removing the word "chronic" was NOT meant to give the benefit a competitive advantage or to cover conditions our competitors did not cover. Claims and medical management felt the benefit was cleaner and easier to administer without it.

None of the examples provided above would be covered as they are all known, scheduled, required, or expected medical care, drugs, or Treatments existent or necessary prior to arrival in the United States and prior to the Effective Date of Coverage. The benefit is never going to cover routine expenses.

An example of something that could be covered under the Acute Onset of Pre-existing Condition benefit would be if a person had type 2 diabetes, that is completely under control for at least 30 days prior to their effective date (including all the other stipulations in the definition) and their blood glucose levels are too high or too low and they have an acute complication. The benefit would cover them until the earliest of (i) the condition no longer being considered acute or (ii) Your discharge from the Hospital.

This benefit should not be marketed or sold as coverage for chronic conditions.

Conclusion:

As you can see from various definitions above, they all have the words like 'sudden', 'unexpected', 'spontaneously', 'without advance warning or symptoms' etc. That itself implies that routine and expected care for chronic medical conditions would not be covered under acute onset of pre-existing conditions. Visitors insurance plans are not designed to and were never meant to cover routine and expected care for chronic medical conditions. In short, the word 'chronic' or lack thereof, in the definition practically makes no difference.

No insurance company would cover routinely expected care for pre-existing conditions as it would simply be an immediate loss to the insurance company. Therefore, any short-term medical insurance such as visitors insurance would not cover them. Don't be misled by an insurance agent or someone trying to sell you something that is telling you anything otherwise.