Pre-existing conditions and underwriting on international health insurance

A pre-existing condition is decided before any benefit applies. IPMIBenefits explains the four underwriting bases, what each means for your cover from day one, and how to protect the cover you already have when you switch.

What a pre-existing condition is

In international private medical insurance (IPMI), a pre-existing condition is any illness, injury or symptom you had before your cover started. Insurers define it broadly: it usually includes anything you had symptoms of, were diagnosed with, took medication for, or received advice or treatment for before the start date, whether or not you knew what it was. Conditions that are related to an earlier one may be treated as the same condition.

The definition matters because a pre-existing condition sits above the whole table of benefits. Before the inpatient limit, the outpatient limit or the chronic condition benefit can apply to a claim, the insurer has to have agreed to cover the condition the claim relates to. If it has not, the claim is declined under every benefit. That is why anyone with medical history should settle the underwriting question before comparing benefits or prices.

Underwriting is the process by which the insurer decides what to cover given your history. The market uses four bases, and the one you are offered shapes what is covered from day one. Not every insurer offers every basis, and some offer only one.

Full medical underwriting (FMU)

Under full medical underwriting you complete a health questionnaire when you apply. You declare your conditions, treatments, medication and consultations, usually over a stated number of years, and sometimes with no time limit for serious conditions. The insurer reviews the answers, may ask for more information or a doctor's report, and then tells you its terms before you buy.

The terms take one of four forms. The condition is accepted and covered on standard terms. It is accepted with a loading, meaning an increased premium. It is excluded, usually by a specific wording on your certificate that names the condition and related conditions. Or the application is declined. Bupa Global describes exactly this range: a declared condition may be covered, possibly for an extra premium, excluded, or restricted, and it adds that any condition not disclosed is not covered.

The strength of full medical underwriting is certainty. You know on day one what is in and what is out, and a declared condition can be accepted. The weaknesses are the effort of the questionnaire and the risk that an honest mistake becomes a problem at claim time. Cigna Global notes that applications must be accurate and complete, that any change in health between applying and the start date must be disclosed, and that deliberately false information can void the policy. Now Health WorldCare underwrites every individual plan this way and offers no moratorium option for individuals. HCI Nimbl states that its plan is subject to full medical underwriting.

Moratorium underwriting

A moratorium turns the process round. You do not complete a medical questionnaire. Instead, the policy automatically excludes any condition you had symptoms, treatment, medication or advice for during a look-back period before you joined. Each excluded condition can then become covered once you have gone a continuous period after joining without symptoms, treatment, medication or advice for it. Conditions that begin after you join are covered from the start.

Expatriate Healthcare publishes a clear example: conditions you had, or were treated or advised on, in the two years before joining are excluded at the start, each becomes covered after two continuous treatment- and symptom-free years following joining, and genuinely new conditions are covered from day one. Allianz Care offers a moratorium option under which pre-existing conditions carry a 24-month waiting period. IMG Global and Optimum Global also list moratorium among their bases.

The strength of a moratorium is simplicity: no questions, quick to arrange, and a condition you had years ago and have not thought about since is covered. The weakness is uncertainty. You do not know whether a claim relates to a pre-existing condition until you make it, and the insurer decides then, looking back at your records. A managed condition that needs continuous medication never has a treatment-free period, so it never clears the moratorium. For someone with ongoing care, full medical underwriting usually gives a better answer, even if that answer is an exclusion, because at least it is known.

CPME and switch terms: moving insurer without losing cover

The third and fourth bases exist for people who already have a plan and want to change insurer without being underwritten from scratch.

Continued personal medical exclusions (CPME)

The new insurer accepts you on the personal exclusions your current insurer applied, and does not underwrite anything else. A condition your current plan covers stays covered; a condition it excludes stays excluded. Nothing new is added. You will usually need to show your current certificate and exclusions, and the new insurer may limit the option to people switching from a comparable plan with no break in cover.

Continued or transfer terms (CTT)

You move onto the new insurer's plan on broadly equivalent terms to your current one, often without a new questionnaire, so conditions already accepted stay accepted. Allianz Care offers this alongside CPME and notes that switch terms must be properly maintained or it may fall back to full medical underwriting. Now Health WorldCare may offer continuous transfer terms or continued personal medical exclusions to people switching from another insurer. IMG Global lists CPME among its bases.

Switch terms matter most for anyone whose current plan covers a condition that fresh underwriting would exclude. The benefit comparison and the price comparison are secondary to one question: can the new insurer carry my existing position across? If it can, you compare benefits and price on that footing. If it cannot, the cheaper plan is not cheaper. A group basis, medical history disregarded, exists for company schemes above a minimum size, but it is not available to individuals.

Which insurers offer which basis

Insurers differ, and the difference is often the reason to choose one over another when you have medical history. From the plan information on their own pages:

• Allianz Care offers a choice of full medical underwriting, moratorium, CPME and transfer terms.
• IMG Global lists full medical underwriting, moratorium, CPME and, for eligible groups, medical history disregarded, and may offer an alternative if the basis you apply for is not available.
• Now Health WorldCare underwrites individuals fully, with transfer terms or CPME on switching.
• Expatriate Healthcare uses moratorium underwriting with no medical questions at application.
• Bupa Global reviews declared history and may cover, load or exclude a condition.
• Optimum Global publishes an individual medical questionnaire, a CPME option and a moratorium guide.
• AXA Global Healthcare states that its plans are designed for conditions beginning after joining and do not cover pre-existing conditions.
• APRIL International requires a health questionnaire and says pre-existing conditions are not systematically covered, so the terms offered after review are decisive.

These positions change, and the terms you are offered are confirmed by the insurer at quote. The insurer pages on this site describe each approach in more detail, and the Cigna versus Allianz comparison looks at two insurers that differ on exactly this point.

What each basis means, benefit by benefit

Because IPMIBenefits compares cover benefit by benefit, it is worth tracing how underwriting lands on each line of the table.

• Inpatient. An admission for an excluded condition is declined in full. An admission for a new condition is covered on every basis.
• Outpatient and chronic conditions. Most ongoing conditions are managed as outpatients, so this is where exclusions bite. Under a moratorium, continuous medication keeps the condition excluded indefinitely.
• Cancer. A past cancer may be excluded with related conditions, loaded, or lead to a decline under full medical underwriting. Monitoring in remission can count as treatment under a moratorium.
• Maternity. An existing pregnancy is pre-existing on every basis. Conditions from an earlier pregnancy may be excluded.
• Mental health. History is reviewed like any other and may be excluded specifically or as a category.
• Evacuation. Only payable for a covered condition. An emergency arising from an excluded condition is not evacuated at the insurer's expense.
• Dental and wellness. Least affected. Waiting periods do most of the work for dental; a check-up is not treatment of a condition, though follow-up of a result linked to an excluded condition is.

How to approach underwriting if you have medical history

1. Write down your history before you start: conditions, dates, treatments, medication, and the last time you had symptoms or advice. You will need it for any questionnaire, and it tells you whether a moratorium could ever clear.
2. Decide what you want to know. If you need certainty about a specific condition, ask for full medical underwriting. If your recent history is clean and you value speed, a moratorium may suit.
3. If you already have cover, ask about switch terms first. CPME or transfer terms can preserve cover that fresh underwriting would remove.
4. Disclose everything. Undisclosed conditions are not covered, and a deliberate omission can void the policy.
5. Compare the terms, not just the price. A plan that excludes your condition is a different product from one that covers it, whatever the premium.
6. Use a broker for the hard cases. Nomi can flag which insurers offer which basis, and an experienced adviser confirms the terms before you buy.

The benefits guide explains the rest of the table once the underwriting answer is in.

Frequently asked questions

This page is general information, not personal or medical advice. Prices are indicative and confirmed by the insurer at underwriting. For advice on your situation, speak to an experienced broker.