Can Group Health Schemes Limit Coverage As A Result Of A Pre-existing Condition?

When it comes to group health insurance plans there is usually confusion because, although some people contend that group health insurance plans are not allowed to exclude you from cover on the basis of your present health or your past medical history, others maintain that they are permitted to refuse cover for pre-existing medical conditions.

The truth is that you cannot be refused membership of a group health insurance plan solely because of you present medical state, including any disability, or because of your prior medical history.

This said, both employers and insurance companies are permitted to question you about any pre-existing medical conditions when you join a scheme or, if you submit a claim during your first year of cover, to look back to establish whether you have a previous history of the condition which gives rise to the claim.

If a pre-existing condition is either reported or found the insurance company or employer may not simply deny you cover but may impose an exclusion period for cover of that particular pre-existing condition. However, there are both federal and state laws which limit the exclusions which employers and insurance companies are permitted to place on their group health plans.

Group health insurance plans may not impose pre-existing condition exclusions as a result of either genetic information or for pregnancy. Furthermore, exclusion periods are not allowed in the case of newborns, newly adopted children or children who are placed for adoption.

In general, pre-existing condition exclusion periods can only be imposed for conditions which are diagnosed within the 6 months before joining a group health scheme for which you have been given (or been recommended to receive) treatment. This period is often called the 'look back' period.

Wherever an exclusion period is imposed it cannot normally exceed 12 months and you must be credited for any previous continuous creditable coverage. In this case cover is classed as continuous where it is not interrupted by a break of more than 63 days in a row. Virtually all private and government sponsored health coverage is considered to be creditable and this will include such things as Medicare, VA coverage, foreign national coverage, military health coverage, individual health insurance, Medicaid, Indian health insurance, student health insurance and more.

When an employer imposes a waiting period for employees to enter a scheme, or an HMO imposes a similar affiliation period, these cannot be included in determining a break in continuous coverage. Further, any pre-existing condition exclusion period has to take account of the waiting or affiliation period with the exclusion period beginning on the first day of the waiting or affiliation period.

When moving between group plans then the new scheme administrator may look at your previous plan in order to calculate any credit towards a pre-existing condition exclusion period for your new plan. This might mean for instance that if the new plan provides cover which was not provided under the previous plan then exclusion periods may be imposed for pre-existing conditions which were not covered before but which are covered under the new plan.

One more point to note is that you have to be given appropriate written notice of any exclusion period and the group scheme administrator has to assist you in obtaining a certificate of creditable coverage from your previous plan if you want him to do so.