Can Group Health Schemes Refuse Cover Because Of A Pre-existing Medical Condition?

Can Group Health Schemes Refuse Cover Because Of A Pre-existing Medical Condition? 
By Donald 

When considering group health insurance schemes there is usually confusion because, while a lot of people argue that group health insurance plans are not allowed to exclude you from cover because of your present health or your previous history, others contend that they are permitted to refuse cover for pre-existing medical conditions.

The reality is that you cannot be refused membership of a group health insurance plan solely as a result of you present health, including any disability that you may have, or as a result of your prior medical history.

However, employers and insurance companies are entitled to question you about any pre-existing medical conditions when you join a plan or, if you make a claim during your first year of cover, to look back to establish whether you have a prior history of the condition which gives rise to the claim.

Whenever a pre-existing condition is reported or discovered the employer or insurance company cannot simply refuse you cover under a group plan but is permitted to require an exclusion period for cover of that particular pre-existing condition. Having said this, there are federal and state laws that control the exclusions that employers and insurance companies are allowed to place on their group health schemes.

Group health insurance schemes are not allowed to apply pre-existing condition exclusions on the basis of pregnancy or genetic information. Further, exclusions are not permitted in the case of newborn babies, newly adopted children and children who are placed for adoption.

Generally speaking, pre-existing condition exclusions are only permitted for conditions that are diagnosed within the 6 months before joining a group health scheme and for which you have been given (or been recommended to have) treatment. This period is frequently known as the 'look back' period.

Where a pre-existing condition exclusion period is required it cannot usually be longer than 12 months and you have to be given credit for any previous continuous creditable coverage. In this case cover is classed as continuous when it is not interrupted by a break in excess of 63 consecutive days. The majority of private and government sponsored health coverage is considered to be creditable and this will include such things as Medicare, student health insurance, military health coverage, Medicaid, Indian health insurance, individual health insurance, foreign national coverage, VA coverage and more.

Where an employer requires a waiting period for individuals to enter a plan, or an HMO requires a similar affiliation period, these cannot be counted in determining a break in continuous coverage. Furthermore, any pre-existing condition exclusion period must take account of the waiting or affiliation period with the pre-existing condition exclusion period starting on the same day as the waiting or affiliation period.

If you are moving from one group plan to another then the administrator of the new scheme is permitted to examine your previous plan for the purpose of calculating any credit towards an exclusion period for your new plan. This may mean for example that if your new plan offers cover that was not provided under the previous plan then exclusion periods may be required for pre-existing conditions that were not formerly covered but that are covered under the 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 has to assist you in obtaining a certificate of creditable coverage for your old plan if you wish him to do so.

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