Denied Insurance Claim for Pre-Existing Condition in Texas? Here's What to Do Next

Introduction

Getting an insurance claim denied can be frustrating—especially when it’s because of something called a “pre-existing condition.” In Texas, insurers sometimes use this term to avoid paying valid claims. But that doesn’t always mean their decision is correct or fair.

If your claim has been denied for a pre-existing condition, it’s important to understand your rights and the steps you can take to fight back. This article will break down what you need to know and how to get the support you need.

What Is a Pre-Existing Condition?

A pre-existing condition is any medical issue, symptom, or diagnosis that you had before your insurance policy began. This could be something as common as high blood pressure or as serious as a previous cancer diagnosis.

Insurance companies often define these conditions broadly. Sometimes, they even argue that a condition you didn’t know about is “pre-existing” if symptoms were present before coverage started.

Here's a simplified way to understand it:

• Diagnosed conditions: Conditions formally diagnosed before coverage.

• Undiagnosed symptoms: Issues you reported or showed signs of before coverage, even if not diagnosed.

• Prior treatments: Any medication, doctor visits, or procedures related to an illness before your policy started.

Why Insurance Companies Deny Claims for Pre-Existing Conditions in Texas

Insurance companies want to avoid paying for expensive treatments they believe are tied to pre-existing issues. Their argument is that they didn’t agree to cover conditions you already had when you signed up.

They might deny your claim if:

• Your medical records show a history of the condition before your coverage began.

• A doctor notes that your current issue may have started before the policy.

• You received treatment—even minimal—for the condition before coverage.

This tactic saves insurers money, but it often leads to unfair denials. Even worse, many denials are based on vague or incomplete information. That’s why it’s important to review your policy and your medical records carefully.

Legal Protections for Policyholders in Texas

Texas law does provide some protections against unfair insurance practices. Here are key legal concepts you should know:

• Texas Insurance Code Chapter 541: Prohibits unfair and deceptive practices by insurers, such as misrepresenting your coverage or using false information to deny a claim.

• Texas Insurance Code Chapter 542: Requires timely handling of claims. Delays without valid reasons can be penalized.

• Bad Faith Denials: If an insurer intentionally denies your claim without a fair investigation, you may have a legal case for bad faith.

In many cases, denials based on “pre-existing conditions” are legally questionable, especially if the condition wasn’t clearly excluded in your policy or wasn’t documented before your coverage began.

How to Respond If Your Claim Is Denied

If your insurance company denies your claim based on a pre-existing condition, here’s what you should do:

Request a Written Explanation

Ask your insurance company for a detailed letter explaining why they denied your claim. They are legally required to provide this.

Review Your Policy

Look at your policy’s language about exclusions and pre-existing conditions. Note what is and isn't covered.

Get a Copy of Your Medical Records

Check the timeline of your treatment and diagnosis. If your condition wasn’t clearly documented before your policy began, you may have a strong case.

Appeal the Denial

Most insurance companies allow appeals. Prepare a written letter, attach evidence, and ask for a reconsideration.

Contact a Lawyer

Insurance law is complex. A skilled attorney can help you understand your rights, build your case, and handle communication with the insurer.

How Louis Law Group Can Help

At Louis Law Group, we help Texans fight back against wrongful insurance denials—including claims denied due to so-called pre-existing conditions. Our attorneys understand the strategies insurance companies use and how to challenge them under Texas law.

We offer:

• Free policy reviews

• Legal representation in appeals

• Litigation support in bad faith denial cases

You don’t have to accept the insurance company’s word as final. With the right help, you can push back and pursue the benefits you deserve.

Frequently Asked Questions (FAQ)

What qualifies as a pre-existing condition under Texas law?

There’s no single definition, but generally, it includes conditions diagnosed or treated before your insurance coverage started.

Can my insurance company deny coverage for any pre-existing condition?

It depends on your policy. Some policies have waiting periods or exclusions, but many denials are made in bad faith and can be challenged.

What if I didn’t know I had the condition?

Even if you weren’t diagnosed, insurers may still argue the condition existed. That doesn’t mean their decision is fair or legal.

Can I appeal the denial on my own?

Yes, but it’s often helpful to consult an attorney who can build a strong legal argument on your behalf.

How long do I have to file an appeal?

Deadlines vary by policy, but usually range from 30 to 180 days. Check your denial letter for specific timelines.

When should I contact an attorney?

If you feel overwhelmed, confused by policy language, or believe the denial was unfair, it’s a good idea to talk to an insurance claims attorney right away.

Conclusion

Having your insurance claim denied due to a pre-existing condition in Texas can be overwhelming—but you’re not powerless. Understanding your policy, gathering the right records, and getting legal help can make all the difference.

If you believe your claim was wrongly denied, you don’t have to go through it alone. Reach out to a professional who knows how to fight back. Louis Law Group has helped many Texans take on unfair insurance practices—and we may be able to help you too.

Are you ready to take the next step to fight your denied insurance claim?

Contact Louis Law Group today for a free consultation. Call 833-657-4812 or submit a free case evaluation form to get started. Don’t wait—let us help you take the first step toward justice and financial recovery.