The plan treats any condition that existed at the time of application, or at any point in the three years before the effective date, as pre-existing. To qualify for the stable pre-existing benefit, the condition must meet a stability test. During the 90 days before the coverage effective date, the condition must not have:
Required hospitalization or emergency medical treatment
Experienced an acute deterioration requiring immediate medical intervention
Been the subject of a physician's recommendation for surgery or other major medical intervention
Required a material change in treatment because of deterioration
Routine follow-up care, maintenance medications taken as prescribed, refills, routine monitoring, preventive care, and adjustments made only to maintain or optimize therapy are not considered a material change in treatment. The insurer may ask for medical records, prescription history, or physician statements to confirm that a condition was stable.
What Is Covered
Expenses related to a stable pre-existing condition are considered when all of the following are true:
The episode is sudden, unplanned, and first occurs after the coverage effective date.
It is a sudden and unplanned recurrence or acute exacerbation of the condition, or a sudden complication that results directly from it, beyond routine maintenance care or expected disease progression.
The treatment is medically necessary and cannot reasonably be delayed.
Multiple episodes can be covered during the same policy period, as long as each one is a separate acute exacerbation that happens after the traveler has been medically stabilized from the previous one, is not a continuation of the same course of treatment and is supported by medical records.
