Articles & News About Health

Can Group Health Schemes Limit My Coverage For A Pre-Existing Condition?

When it comes to group health insurance schemes there is frequently confusion because, while some people maintain that group health insurance plans are not allowed to exclude you from cover as a result of your present health or your previous history, others claim that they are permitted to refuse cover when it comes to pre-existing conditions.

It is in fact true that you may not be denied membership of a group health insurance plan solely as a result of you present medical state, which includes any disability, or because of your prior medical history.

But, insurers and employers are entitled to ask you if you have any pre-existing medical conditions when you join a plan or, if you submit a claim during your first year of coverage, to look back in order to establish whether you have a previous history of the condition which gives rise to the claim.

Where a pre-existing condition is reported or found the employer or insurer cannot simply refuse you coverage under a group plan but is permitted to impose an exclusion period for coverage of that specific pre-existing condition. This said, there are federal and state laws which govern the exclusions which insurers and employers are allowed to place on their group health schemes.

Group health insurance schemes are not permitted to impose pre-existing condition exclusions as a result of pregnancy or genetic information. Further, exclusion periods are not allowed for newborn babies, newly adopted children and children placed for adoption.

In general terms, pre-existing condition exclusion periods are only allowed for conditions which are diagnosed within the 6 months prior to joining a group health scheme and for which you have been given (or been recommended to have) treatment. This 6 month period is normally known as the 'look back' period.

When an exclusion period is required it may not usually be longer than 12 months and you have to be given credit for any previous continuous creditable coverage. Here cover is considered to be continuous where it is not interrupted by a break of more than 63 days in a row. Almost all private and government sponsored health coverage is classed as creditable and this will include such things as Medicare, individual health insurance, student health insurance, Indian health insurance, foreign national coverage, VA coverage, Medicaid, military health coverage and much more.

Where an employer imposes a waiting period for people to join a plan, or an HMO imposes a similar affiliation period, these may not be included in determining a break in continuous coverage. Furthermore, any pre-existing condition exclusion period has to take into account the waiting or affiliation period with the pre-existing condition exclusion period beginning on the same day as the waiting or affiliation period.

If you are moving between group plans then the administrator of your new plan is permitted to look at your old plan to calculate any credit entitlement towards an exclusion period for your new plan. This could mean for instance that if your new plan offers cover which was not provided under your old plan then exclusion periods can be required for pre-existing conditions which were not formerly covered but which are covered under your new plan.

One more point worth noting is that you must be given appropriate written notice of any pre-existing condition exclusion period and the group plan administrator must help you to obtain a certificate of creditable coverage for your old plan if you want him to do so.

MedicalHealthInsuranceToday.com provides information on everything from finding a health insurance scheme for pre-existing conditions to cheap travel health insurance

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