Can Group Health Schemes Limit My Cover As A Result Of A Pre-Existing Condition? - By: Don Saunders

When considering group health plans there is usually confusion because, although a lot of people maintain that group health plans cannot refuse you cover as a result of your current health or your past medical history, others maintain that they are permitted to refuse cover when it comes to pre-existing conditions.

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

However, insurers and employers are entitled to question you about any pre-existing medical conditions when you join a plan or, if you submit a claim during your first year of coverage, to look back in order to see if you have a previous history of the condition which gives rise to the claim.

If a pre-existing condition is either reported or found the insurance company or employer cannot simply deny you coverage under a group plan but may require an exclusion period for coverage of that particular pre-existing condition. This said, there are federal and state laws which control the exclusions which insurers and employers are permitted to place on their group health plans.

Group health plans may not apply pre-existing condition exclusion periods as a result of either pregnancy or genetic information. Furthermore, exclusion periods are not allowed for newborns, newly adopted children or children who are placed for adoption.

In general, pre-existing condition exclusion periods are only allowed for conditions which 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 usually called the 'look back' period.

If a pre-existing condition exclusion period is imposed it cannot usually exceed 12 months and you must be credited for any previous continuous creditable coverage. In this case cover is said to be continuous if it has not been interrupted by a break of more than 63 consecutive days. Almost all private and government sponsored health coverage is considered to be creditable and this will include such things as Medicare, individual health insurance, Indian health insurance, Medicaid, military health coverage, VA coverage, foreign national coverage, student health insurance and much more.

When an employer requires a waiting period for employees to join a plan, or an HMO requires a similar affiliation period, these cannot be included in calculating a break in continuous coverage. Furthermore, pre-existing condition exclusion periods must take into account the waiting or affiliation period with the pre-existing condition exclusion period starting on the first day of the waiting or affiliation period.

When moving between group schemes then the administrator of your new scheme may examine your previous plan in order to calculate any credit entitlement towards an exclusion period for your new plan. This might mean for instance that if the new plan provides cover which was not provided under your previous plan then exclusion periods may be imposed for pre-existing conditions which were not covered before but which are covered under your new plan.

One final point to note is that you must be given appropriate written notice of any pre-existing condition exclusion period and the group plan administrator must help you to obtain a certificate of creditable coverage for your previous plan if you want him to do so.

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