Can Group Health Plans Limit My Cover For Pre-Existing Conditions?

When it comes to group health insurance schemes there is normally confusion because, while a lot of people argue that group health insurance plans cannot refuse you cover because of your current health or your previous medical history, other people argue that they can in fact refuse cover when it comes to pre-existing medical conditions.

It is in fact the case that you cannot be denied membership of a group health insurance plan solely as a result of you current health, including any disability, or as a result of your prior medical history.

Having said this, both employers and insurance companies are permitted to ask you if you have any pre-existing medical conditions when you join a scheme or, if you submit a claim in the first year of cover, to look back in order to establish whether you have any past history of the condition which is the subject of your claim.

Where a pre-existing condition is either reported or discovered the employer or insurer may not simply deny you cover but is allowed to require an exclusion period for cover of that specific pre-existing condition. However, there are both federal and state laws which govern the exclusions which employers and insurance companies are allowed to place on their group health schemes.

Group health insurance schemes are not allowed to impose pre-existing condition exclusions as a result of either genetic information or for pregnancy. Further, exclusion periods are not allowed for newborns, newly adopted children and 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 prior to joining a group health scheme and for which you have received (or been recommended to receive) treatment. This 6 month period is frequently referred to as the 'look back' period.

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

If an employer requires a waiting period for employees to join a scheme, or an HMO requires a similar affiliation period, these cannot be counted in calculating any break in continuous coverage. Additionally, any pre-existing condition exclusion period must take account of the waiting or affiliation period with the exclusion period beginning on the same day as the waiting or affiliation period.

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

One more point to note is that you must 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 former plan if you wish him to do so.

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