Can Group Health Insurance Plans Refuse Cover Because of A Pre-Existing Medical Condition?

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There is generally confusion when talking about group health plans because, while some people say that group plans are not allowed to refuse you cover on the basis of your present health or your prior history, other people maintain that they are permitted to refuse cover when it comes to pre-existing medical conditions.

It is certainly the case that you may not be refused membership of a group plan solely because of you present health, which includes any disability which you may be suffering from, or as a result of your past medical history.

But, both insurers and employers are permitted to ask you if you have any pre-existing medical conditions at the time of enrollment or, if you make a claim during your first year of coverage, to look back in order to establish whether you have a past history of the condition which gives rise to the claim.

If a pre-existing condition is reported or found the employer or insurance company may not simply refuse you coverage under a group plan but can require an exclusion period for coverage of that particular pre-existing condition. This said, there are both federal and state laws which regulate the exclusions which insurers and employers can place on their group plans.

Group health plans may not impose pre-existing condition exclusions because of genetic information or for pregnancy. Additionally, exclusions are not allowed in the case of newborns, newly adopted children or children who are placed for adoption.

In general terms, pre-existing condition exclusions can only be imposed for conditions which are diagnosed within the 6 months before joining a group scheme and for which you have had (or been recommended to have) treatment. This period is usually referred to as the 'look back' period.

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

When an employer requires a waiting period for individuals to join a plan, or an HMO requires a similar affiliation period, these may not be included in calculating a break in continuous coverage. Further, any pre-existing condition exclusion period must take account of the waiting or affiliation period with the exclusion period starting on the first day of the waiting or affiliation period.

When moving from one group plan to another then the administrator of the new plan can examine your previous plan to work out any credit towards a pre-existing condition exclusion period for your new plan. This may mean for instance that if the new plan offers cover which was not provided under the previous plan then exclusion periods may be required for pre-existing conditions which were not covered before but which are covered under the new plan.

One final point to note is that you have to be given appropriate written notice of any exclusion period and the group plan administrator must help you to obtain a certificate of creditable coverage for your old plan if you wish him to do so.

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

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