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Can Group Health Insurance Schemes Refuse My Coverage As A Result Of Pre-Existing Conditions? |
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Written by Webmaster
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Sunday, 09 December 2007 |
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By Donald Saunders
 When looking at group health insurance plans there is often confusion because, although a lot of people maintain that group insurance plans may not refuse you cover as a result of your present health or your past medical history, others say that they are permitted to refuse cover in the case of pre-existing conditions.
The reality is that you may not be refused membership of a group insurance plan solely as a result of you present health, including any disability that you might have, or as a result of your previous medical history.
Having said this, insurance companies and employers 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 in order to establish whether you have a previous history of the condition which is the subject of your claim.
When a pre-existing condition is either reported or found the employer or insurer cannot simply deny you cover under a group plan but is permitted to impose an exclusion period
for cover of that particular pre-existing condition. However, there are federal and state laws that regulate the exclusions that insurance companies and employers may place on their group plans.
Group health insurance plans are not permitted to apply pre-existing condition exclusion periods because of either genetic information or for pregnancy. Furthermore, exclusions are not permitted for newborn babies, newly adopted children and children placed for adoption.
In general, pre-existing condition exclusions are only permitted for conditions that are diagnosed within the 6 months prior to joining a group scheme for which you have received (or been recommended to have) treatment. This period is often referred to as the 'look back' period.
Wherever a pre-existing condition exclusion period is imposed it may not generally exceed 12 months and you must be credited for any previous continuous creditable coverage. In this case cover is said to be 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 classed as creditable and this will include such things as Medicare, Indian health insurance, student health insurance, VA coverage, military health coverage, foreign national coverage, individual health insurance, Medicaid and more.
Where an employer imposes a waiting period for employees to enter a plan, or an HMO imposes a similar affiliation period, these may not be counted in determining a break in continuous coverage. Furthermore, pre-existing condition exclusion periods have to take into account the waiting or affiliation period with the exclusion period beginning on the same day as the waiting or affiliation period.
When moving from one group plan to another then your new scheme administrator is permitted to examine your old plan in order to calculate any credit towards a pre-existing condition exclusion period for your new plan. This might mean for example that if the new plan provides cover that was not provided under your old plan then exclusion periods can be imposed for pre-existing conditions that were not covered before but that are covered under your 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 assist you in obtaining a certificate of creditable coverage from your former plan if you wish him to do so.
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Last Updated ( Sunday, 09 December 2007 )
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