Pre-existing condition
A policy exclusion with clocks and causation — not ‘anything a doctor ever wrote’. Look-back window , disablement window, and what actually caused duties to stop.
This is
- A clause that can exclude disablement caused by a condition known, treated, or symptom atic in a defined period before cover
- Often two clocks on South African group wording: look-back (commonly six months) and first twelve months of cover
- In Australia, a PDS definition plus Insurance Contracts Act s 47 (awareness) — and a separate non-disclosure remedy
- A matter the insurer usually has to prove, with contemporaneous notes, not a later summary
This is not
- Every old diagnosis on a script or medical-aid history
- Automatically the same as non-disclosure or a retrospective exclusion added at claim stage
- Proved by a historic injury years before the look-back (NFO CR403)
- Still alive on typical SA group wording if disablement falls after the first twelve months (NFO CR356)
ClaimBuddy resources
Cross-links to Clinical Atlas, glossary, traps, and policy terms — hover for a quick summary.
South Africa and Australia
Same idea, different clocks. The session jurisdiction is highlighted; both readings stay on the page because group wordings travel with the person.
South Africa — how pre-existing exclusions usually work
Group IP in South Africa is often a two-limb, time-limited exclusion. The insurer carries the onus. Historic labels are not the test.
Most South African group income-protection and lump-sum disability wordings do not exclude every illness you ever had. They exclude disablement that is caused by a condition you knew about, were treated for, or had symptoms of in a short look-back (commonly six months before entry), and — on many group contracts — only if that disablement happens in the first twelve months of cover (NFO CR356).
Retail policies and credit life can be harsher: some exclude a pre-existing condition for the life of the benefit, or use ‘directly or indirectly’. Even then the NFO still asks for proof of the condition in the defined window and a causal link to the claim event (CR403, CR351). Policyholder Protection Rules require reasonable steps to gather information and fair treatment — asserting an old script without investigating post-cover change is the usual fight.
Underwriting path matters. If the insurer asked medical questions and issued cover, a later ‘pre-existing’ decline may really be a non-disclosure argument, which has its own rules. If cover was automatic (fund / union) with no questions, the exclusion clause is doing the underwriting after the fact — read it strictly.
- Limb 1 — look-back Did the person know of, receive advice or treatment for, or have symptoms of the claiming condition in the look-back months before cover? Contemporaneous notes, not a later narrative.
- Limb 2 — disablement window On typical group wording: did disablement occur in the first twelve months after entry? If duties stopped after that window, the exclusion often falls away even if limb 1 is true.
- Limb 3 — causation Was the disablement caused by that look-back condition, or by a new post-cover event / material deterioration that the clause does not capture? Historic injury ≠ proof (CR403).
- Onus The insurer must prove the exclusion on a balance of probabilities. Gaps in the look-back file are the insurer’s problem if it could have obtained the notes (CR403).
If it is declined. Internal review at the insurer, then the NFO Life Insurance Division (free).
Australia — PDS exclusion, s 47 awareness, and disclosure
Three different tools: the PDS pre-existing wording, Insurance Contracts Act s 47 (awareness), and non-disclosure / misrepresentation remedies.
Retail life and IP policies define ‘pre-existing’ in the PDS — often awareness, symptoms a reasonable person would notice, treatment, investigation, or a chronic illness in a 12-month (sometimes longer) window. Group cover inside super frequently applies a 12-month pre-existing limitation on automatic acceptance. AFCA applies the PDS words, then tests whether the Act stops the insurer using them.
Section 47 ICA: the insurer cannot rely on a pre-existing exclusion if, before entry, the person was not aware of the condition and a reasonable person in those circumstances could not be expected to have been aware of it. AFCA’s approach is that awareness is not the diagnosis stamp and not a fleeting ache — GP notes, referrals, and scans in the pre-inception window decide it.
A different fight is duty of disclosure (older contracts) or the duty to take reasonable care not to make a misrepresentation (from 5 October 2021 for consumer contracts). Remedies live in ICA s 29: avoid, vary, or reduce. AFCA will not let a retrospective exclusion go further than a prudent insurer would have gone. Do not collapse these into one ‘they said it was pre-existing’ paragraph.
- PDS definition Does the claimed condition meet the policy’s own definition (treatment, investigation, reasonable-person symptoms, chronic illness) in the stated window?
- s 47 awareness Even if the PDS is met, was the person actually aware, and would a reasonable person have been aware, of that condition before the contract? If both answers are no, the exclusion is blocked.
- Causation Is the claim ‘arising from’ that condition, or from a new injury or illness after cover? Aggravation clauses are common — read them; they are not automatic.
- Disclosure / s 29 If the insurer is really saying ‘you didn’t tell us’, that is not the exclusion. It is a separate remedy with its own onus and time limits.
If it is declined. Internal dispute resolution (RG 271), then AFCA. Super claims often need the trustee as well as the insurer.
NFO and AFCA — guidance and precedent
Published holdings and approach documents. They illustrate how the offices read typical wording. They are not binding on your insurer and not advice on your file.
NFO · CR403 · 2024
Pre-existing condition clause — onus and look-back proof
The insurer must prove, on a balance of probabilities, both that the look-back condition existed in the contractual window and that it caused the disablement. A historic injury and a broad ‘chronic since 2003’ sentence are not enough. First consultation in the file was 8 March 2017; a June 2016 heavy-vehicle medical had given a clean bill of health; the leg weakness the insurer relied on started in 2017, after cover.
Claim paid after the office put the insurer to proof.
NFO · CR356 · 2014
Two-limb pre-existing exclusion — look-back and first twelve months
Typical South African group wording is conjunctive. The insurer needed (a) knowledge, diagnosis, treatment or symptoms of the claiming condition in the six months before entry, AND (b) disablement in the first twelve months after entry. Limb (a) was met; limb (b) was not. Symptoms in the look-back do not keep the exclusion alive once disablement falls outside the first year.
Insurer accepted the office’s reading and paid.
NFO · CR351 · 2014
Pre-existing exclusion — proximate cause, not every historic diagnosis
The exclusion turns on whether the pre-existing condition caused the claim event, not on whether any old diagnosis exists. Medical evidence at cancer diagnosis recorded no cardiac involvement. Historic disease in the background is not automatically ‘directly or indirectly’ the cause.
Office distinguished the pre-existing cardiac history from later cancer as the cause of death.
AFCA · AFCA Approach — ICA s 47 · 2024
Section 47: awareness of a pre-existing condition, not the diagnosis label
If, before the contract, the consumer was not aware of the condition and a reasonable person in those circumstances could not be expected to have been aware of it, s 47 stops the exclusion. Awareness sits between a stray symptom and a stamped diagnosis: consultations, investigations, and contemporaneous GP notes carry the weight. Later recollection that ‘it was nothing’ is often discounted. Awareness of the condition at any time before entry defeats s 47, even if the person reasonably believed they no longer had it.
Approach document — applied in published determinations.
AFCA · AFCA Approach — life insurance non-disclosure · 2025
Non-disclosure remedies are not a substitute pre-existing clause
A s 29(6) variation must put the insurer in the position a reasonable and prudent insurer would have been in at entry. AFCA may narrow or strip a retrospective exclusion that other prudent insurers would not have applied. Declining the claim and varying the contract are two decisions; each needs its own proof. An exclusion that does not cover the claimed condition does not save a bad variation.
Approach document — ICA s 29 variation is a different tool from an exclusion.
See it, then try it
Click a sketch, then move the months. The strip is months relative to cover start. S = first symptoms, T = first treatment, N = new event, D = duties stopped. Illustrative clocks, not your clause. Typical South African group pattern: six-month look-back and a first-twelve-months disablement window, plus causation. Australian PDS windows and s 47 awareness differ. Not a decision on a claim.
Limb 1
Look-back
Symptoms or treatment inside the months before cover.
Limb 2
First-year disablement
Duties stopped inside the first twelve months — off if the sketch has no cap.
Limb 3
Causation
Disablement caused by the look-back condition, not a later new event.
Australia · s 47
Awareness
Pre-inception symptoms or treatment — a reasonable-person question, not a diagnosis stamp.
How do you know?
Practical signs that this term applies to your situation — not legal advice.
- The decline letter says ‘pre-existing’ but quotes a diagnosis from years before the look-back months.
- You were treated for something in the look-back, then a different acute event after cover stopped the job.
- Disablement (duties stopped) is more than twelve months after group entry — many SA clauses then fall away.
- In Australia, you had symptoms but no investigations before inception — s 47 awareness is the live question.
- The same letter also says you failed to disclose: that is a second ground, with different proof.
What triggers it?
Events or thresholds that typically activate this concept in a claim.
- Any decline that uses ‘related to’, ‘traceable to’, or ‘directly or indirectly’ a history before cover.
- Automatic group or super cover issued without medical questions — the exclusion is doing the underwriting.
- A stable chronic condition plus a new post-cover event (infection, injury, acute psychiatric episode).
- Date-of-absence disputes that pull the disablement date back into the first twelve months.
- Retail application forms: later s 29 variation or a retrospective exclusion instead of the PDS clause.
Check yourself
Highlighted words link to language-map explainers.
- What is the cover start or fund entry date on the schedule — not the day I joined the employer?
- Which months are the look-back , and is there a first-year disablement window?
- What contemporaneous notes exist in those months — advice, treatment, investigations, symptoms ?
- When did material duties actually stop, and is that inside the disablement window?
- What caused the stop: the look-back condition , or a new event / material change after cover?
- If this is Australia: was I aware, and would a reasonable person have been aware, of that condition before entry?
Date ladder
These dates are rarely the same day — capture each one separately in ClaimBuddy.
- Look-back opens Usually a fixed number of months before cover start — six is common on SA group files
- Cover start / entry Member certificate or schedule, not employment start if they differ
- First-year window closes On typical SA group wording, disablement after this date is outside the exclusion
- New event (if any) Post-cover injury, infection, or acute change — the usual causation split
- Duties stopped (DOA) The disablement clock — not first symptom and not the diagnosis stamp
How this links to other terms
Look-back and first-year windows run from entry / commencement, not first symptom.
Disablement date is the second clock — pulling it earlier can wrongly trigger the exclusion.
A historic label is not look-back proof and not automatically the cause of disablement.
You can be ill before cover; the clause asks whether that illness caused this disablement in the window.
Waiting period is about when benefits start; pre-existing is about whether the claim is excluded.
Beating the exclusion does not win the claim — the occupational test remains.
Evidence
Cover start / entry date, look-back medical notes, occupation al-health or fitness clearances just before cover, first advice or treatment dates, new-event records, date duties stopped, treating opinion on causation
Often mixed with
Confusion drill-downs
Side-by-side guides for pairs people mix up with Pre-existing condition.
Back injury in 2003, cover in 2016, leg weakness from 2017 — the 2003 label is not the six-month look-back the clause asked for.