Pre-Existing Condition
Any illness, injury, symptom, or medical condition that existed, was diagnosed, showed symptoms, or for which treatment was received or recommended before the policy commencement date or during applicable waiting periods. Coverage for pre-existing conditions depends on disclosure, underwriting assessment, and policy terms.
Detailed Explanation
Pre-existing conditions represent a critical concept in Australian life insurance affecting coverage eligibility, pricing, exclusions, and claims outcomes. The definition varies slightly between insurers but generally encompasses: Conditions diagnosed before policy commencement; Conditions for which symptoms were present before commencement regardless of diagnosis; Conditions for which medical consultation, investigation, or treatment occurred or was recommended before commencement; and Underlying conditions manifesting in related ways post-commencement. The duty of disclosure under Section 21 of the Insurance Contracts Act 1984 requires applicants to disclose all pre-existing conditions and medical history relevant to the insurer's decision to provide coverage. Disclosure must occur even if: The applicant didn't know the medical significance; The condition seemed minor or resolved; Treatment was brief or years ago; The applicant didn't receive a formal diagnosis. Underwriting assessment of disclosed pre-existing conditions results in several possible outcomes: Standard acceptance if condition is minor, fully resolved, or doesn't impact mortality/morbidity risk; Premium loading (percentage increase) to account for elevated risk while providing full coverage; Specific exclusion removing coverage for claims relating to the disclosed condition; Postponement of coverage until condition resolves or stabilizes; or Decline if condition presents unacceptable risk. Non-disclosed pre-existing conditions create significant claim risks: Within the three-year contestability period, insurers can investigate application accuracy if claims arise; If non-disclosure of a pre-existing condition is proven, Section 54 protections still apply - insurers can only decline or reduce claims if the non-disclosed condition caused or contributed to the claimed loss; For example, non-disclosed diabetes cannot justify declining a claim for accidental death in car accident; Complete non-disclosure of all medical history may void the policy entirely for fraudulent misrepresentation. The interaction between pre-existing conditions and different insurance types varies: Life insurance may cover pre-existing conditions without exclusion if disclosed and accepted (as coverage is for death from any cause); TPD insurance typically excludes pre-existing conditions or applies specific exclusions as disabilities often relate to ongoing health conditions; Income protection frequently includes pre-existing condition clauses imposing 12-24 month waiting periods before coverage begins for disclosed conditions; Trauma insurance may cover some pre-existing conditions (e.g., previous heart attack doesn't prevent cancer claim) while excluding recurrences. Common pre-existing conditions include: Cardiovascular conditions (high blood pressure, high cholesterol, previous heart attack); Mental health conditions (depression, anxiety, previous psychiatric treatment); Musculoskeletal conditions (back pain, arthritis, previous surgeries); Metabolic conditions (diabetes, thyroid disorders); Previous cancers; and Chronic conditions (asthma, sleep apnea). Recent industry developments improve pre-existing condition management: Better risk assessment enabling coverage of more conditions with appropriate pricing; Clearer pre-existing condition definitions in policy documentation; Improved disclosure processes with specific health questions rather than open-ended requests; Time-limited exclusions that may be removed after periods of stability; and Regular monitoring enabling coverage expansion as conditions stabilize. Consumer strategies include: Complete honest disclosure of all medical history regardless of perceived relevance; Obtaining medical records to ensure accurate disclosure of conditions you may have forgotten; Working with advisers who can present applications favorably while maintaining disclosure obligations; Shopping multiple insurers as different underwriters assess pre-existing conditions differently; Accepting coverage with exclusions if alternative is no coverage; and Requesting regular exclusion reviews if conditions improve or resolve. Medical advances changing pre-existing condition landscapes include: Conditions previously uninsurable now accepted with loadings (HIV on antiretroviral therapy, some cancers after specific remission periods); Improved understanding of mental health enabling more nuanced risk assessment; Genetic testing knowledge (though moratorium prevents insurers requesting tests for most policies); and Better predictive tools for condition progression and mortality impact.
Common Misconceptions
- •Pre-existing conditions can never be covered - Many pre-existing conditions are covered with standard premiums, loadings, or exclusions rather than automatic decline
- •If you don't remember a medical issue, you don't need to disclose it - Duty of disclosure applies to all matters a reasonable person would consider relevant, regardless of memory; insurers access medical records that may reveal forgotten conditions
- •Pre-existing conditions mean the whole policy is void if discovered - Section 54 protections ensure only claims caused by non-disclosed pre-existing conditions can be affected; unrelated claims must still pay
Real-World Examples
An applicant discloses well-controlled Type 2 diabetes. Underwriter applies 25% premium loading but provides full coverage with no exclusions. Ten years later, death from cancer claim pays in full despite diabetes loading, as coverage was comprehensive.
A policyholder fails to disclose previous episodes of depression. Three years later, TPD claim for severe psychiatric disability is submitted. Insurer investigates, discovers non-disclosure, and declines claim under Section 54 as non-disclosed depression directly relates to current mental health disability claim.
An applicant discloses previous lower back surgery. Insurer offers coverage with specific exclusion for 'any claims arising from or relating to lower back conditions.' Five years later, neck injury causing permanent disability results in TPD claim. Despite back exclusion, claim pays as neck injury is separate condition not related to excluded lower back area.
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Related Terms
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- UnderwritingThe risk assessment process where insurers evaluate an applicant's health, lifestyle, occupation, and financial circumstances to determine eligibility for coverage and appropriate premium pricing. This critical evaluation ensures fair pricing based on individual risk profiles.
- Policy ExclusionsSpecific circumstances, conditions, activities, or causes of death or disability explicitly excluded from coverage under insurance policy terms. These exclusions can be standard (applying to all policies) or specific (applied to individual applicants due to underwriting assessment), and permanently remove coverage for excluded scenarios.
- Policy ExclusionsSpecific conditions, activities, or circumstances that are not covered by your insurance policy. Exclusions define what the insurer will not pay for, such as pre-existing conditions, self-inflicted injuries, dangerous activities, or war-related events. Understanding exclusions is critical to knowing when you're actually covered.
- Duty of DisclosureThe previous consumer obligation requiring policyholders to disclose all relevant matters to insurers, now largely replaced by the duty to take reasonable care for consumer insurance contracts.