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Can Group Health Insurance Plans Restrict My Coverage Because Of Pre-existing Conditions?
When looking at group health schemes there is normally confusion because, although a lot of people contend that group health plans may not refuse you cover on the basis of your present health or your prior history, other people contend that they can in fact refuse cover when it comes to pre-existing medical conditions.
It is in fact true that you cannot be refused membership of a group health plan solely because of you present health, which includes any disability that you may have, or as a result of your prior medical history.
Nonetheless, both insurance companies and employers are allowed to question you about any pre-existing medical conditions at the time of enrollment or, if you submit a claim during your first year of coverage, to look back in order to see if you have a past history of the condition which gives rise to the claim.
When a pre-existing condition is either reported or found the insurer or employer may not simply refuse you coverage but is permitted to impose an exclusion period for coverage of that specific pre-existing condition. Having said this, there are both federal and state laws that govern the exclusions that insurance companies and employers can place on their group health schemes.
Group health schemes cannot apply pre-existing condition exclusions as a result of either genetic information or for pregnancy. Furthermore, exclusion periods are not allowed for newborns, newly adopted children or children placed for adoption.
In general, pre-existing condition exclusion periods can only be imposed for conditions that 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 period is generally referred to as the 'look back' period.
Where an exclusion period is imposed it cannot usually exceed 12 months and you must receive credit for any previous continuous creditable
coverage. Here cover is classed as continuous where it has not been interrupted by a break in excess of 63 consecutive days. Virtually all government sponsored and private health coverage is considered to be creditable and this will include such things as Medicare, Indian health insurance, student health insurance, foreign national coverage, individual health insurance, Medicaid, military health coverage, VA coverage and much more.
If an employer requires a waiting period for employees to enter a plan, or an HMO requires a similar affiliation period, these cannot be included in calculating a break in continuous coverage. Furthermore, 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.
If you are moving from one group plan to another then the new scheme administrator is permitted to examine your previous plan for the purpose of calculating any credit entitlement towards an exclusion period for your new plan. This may mean for example that if the new plan offers cover that was not provided under the previous plan then exclusion periods can be imposed 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 have to be given appropriate written notice of any exclusion period and the group plan administrator has to help you to obtain a certificate of creditable coverage from your old plan if you wish him to do so.
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