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A pre-existing condition is any medical condition or disease that a person already has before enrolling in a health insurance policy. This condition may be chronic or long-term and can range from serious illnesses like cancer to less severe ailments such as asthma, acne, or high blood pressure. Health insurers may not be willing to provide insurance coverage to people with pre-existing medical conditions. A comprehensive analysis of the medical records using medical review services helps reveal any pre-existing health conditions the insurance applicant may have. Medical records review is an evaluation process that insurers use to determine the medical necessity for a healthcare service or procedure. The review process helps them determine the insurance premiums.
Individuals with pre-existing health issues are commonly required to undergo a pre-policy medical checkup, which serves as the basis for determining their insurance premium. If the results of the checkup are unfavorable, the insurer may refuse to provide coverage or reduce the policy coverage. Some insurers may also include a co-payment clause for pre-existing conditions coverage.
Medical chart review brings to light any health issues that could have an impact in the long run. By reviewing the applicant’s entire medical history, the insurer looks for illnesses with long-term side effects and does not consider short-term health issues as pre-existing illnesses.
Health insurers use the services of a professional medical review company to organize the medical records properly and review them on time so that the core medical facts are available. The medical data is presented in an easily comprehensible format, which makes it easier for the health insurer to arrive at the right coverage decision.
Check out the infographic below