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Merritt Personal Lines Manual: Chapter 11 Pre-Existing Conditions

Most LTC policies also will contain a six-month pre-existing condition provision, which means the policy will not pay any benefits for a pre-existing condition during the first six months that the policy is in force. (State laws usually prevent insurance companies from having a pre-existing condition limitation that is greater than six months.) More liberal policies may state that all pre-existing conditions are covered as of the effective date of the policy, if the condition is stated on the application.

A pre-existing condition usually is defined as any injury or illness for which medical treatment or advice was received or recommended within a certain period of time prior to the effective date of coverage.

For example, Mike saw his doctor June 1 for a back problem. On September 1, he applies for LTC coverage. Mike must answer yes to any question on the application regarding pre-existing conditions. If Mike's policy contains a six-month pre-existing condition provision, any nursing home stay due to his bad back will not be covered for the first six months of the policy.

What if Mike doesn't see his doctor about his bad back, but he does call him and the doctor prescribes some medication over the phone? Does Mike have a pre-existing condition? Yes, because he has received advice (and medication) from the doctor regarding the condition.

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