Pre-Existing Conditions in Pennsylvania

This blog post was inspired by a recent comment on our blog. If you have any questions on any of our blog posts, please feel free to put them in the comment sections.

Question: Does Pennsylvania allow insurance companies to discriminate against people with pre-existing conditions?

Answer: Yes, with some exceptions.

During the heath care debate, a lot of time has been spent discussing the need to prohibit insurance companies from denying coverage or charging higher premiums because an individual has what they consider a pre-existing condition.

In Pennsylvania, you must have received medical attention for your condition, which includes medical advice, a diagnosis, or actual treatment, for it to be considered a pre-existing condition. This is a higher standard then other states, which allow undiagnosed symptoms to also be considered pre-existing conditions as well.

Even with Pennsylvania’s high standard, many policies will not pay benefits for pre-existing conditions, or will only cover treatment of them after the policy has been in force for a specified period of time. The time period varies depending on whether the policy is group or individual coverage. In the individual market, insurers are permitted to look into previous medical history for a maximum of 60 months to determine if you have a pre-existing condition. In the group market, the maximum look back period is 6 months.

Other facts about health insurance in Pennsylvania:
  • Insurance companies are required to include 38 benefits in all individual insurance plans, which is the same as the national average of 38.4. These benefits do not include basic benefits such as maternity services, cancer medications, and diabetes self-management.
  • There is no limit on how much insurers can charge individual policyholders for health insurance.
  • Insurers are allowed to permanently exclude pre-existing conditions from an individual’s coverage, which means that some individuals will never be able to purchase health insurance for their medical conditions on the individual market.
  • Insurers can deny coverage based on health status at the time of application, limiting care for anyone with less than perfect health. This means that those individuals who obtain coverage but are found to have omitted a pre-existing condition on their insurance applications can have their coverage canceled, rescinded (retroactively canceled), or limited through a preexisting condition exclusion.
  • Consumers are not given the right to appeal a decision by their insurer to rescind or cancel their coverage.


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