Can Group Health Schemes Refuse Coverage As A Result Of Pre-existing Medical Conditions?

By Author: Donald Saunders
Total Articles: 84
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When considering group health schemes there is generally confusion because, while a lot of people claim that group health plans may not refuse you cover as a result of your current health or your prior medical history, other people say that they are permitted to refuse cover for pre-existing conditions.

It is certainly the case that you cannot be refused membership of a group health plan solely because of you current health, including any disability that you might be suffering from, or because of your past medical history.

Nevertheless, employers and insurance companies are allowed to question you about any pre-existing medical conditions on enrollment or, if you submit a claim in the first year of coverage, to look back to establish whether you have any prior history of the condition which gives rise to the claim.

When a pre-existing condition is reported or unearthed the insurance company or employer 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 federal and state laws that govern the ...
... exclusions that employers and insurance companies are allowed to place on their group health schemes.

Group health schemes are not allowed to impose pre-existing condition exclusions because of pregnancy or genetic information. Further, exclusion periods are not allowed in the case of newborn babies, newly adopted children and children placed for adoption.

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

If an exclusion period is required it cannot normally be longer than 12 months and you must be given credit for any previous continuous creditable coverage. In this case cover is said to be continuous where it is not interrupted by a break in excess of 63 consecutive days. Almost all government sponsored and private health coverage is classed as creditable and this will include such things as Medicare, military health coverage, student health insurance, Indian health insurance, individual health insurance, Medicaid, foreign national coverage, VA coverage and more.

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

If you are moving between group plans then the new plan administrator can look at your previous plan to calculate any credit entitlement 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 can be required for pre-existing conditions that were not covered before but that are covered under the new plan.

One final point worth noting is that you have to be given appropriate notice of any pre-existing condition exclusion period in writing and the group plan administrator is obliged to help you to obtain a certificate of creditable coverage from your previous plan if you wish him to do so.