When considering group health insurance schemes there is usually confusion because, while a lot of people contend that group insurance plans may not refuse you cover as a result of your present health or your past medical history, others argue that they are permitted to refuse cover for pre-existing conditions.
The reality is that you may not be denied membership of a group insurance plan solely because of you present health, which includes any disability, or because of your past medical history.
Nonetheless, 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 in the first year of coverage, to look back to see if you have any previous history of the condition which gives rise to the claim.
If a pre-existing condition is either reported or discovered the insurer or employer cannot simply deny you coverage but may require an exclusion period for coverage of that particular pre-existing condition. Having said this, there are federal and state laws that regulate the exclusions that insurance companies and employers are allowed to place on their group schemes.
Group health insurance schemes may not impose pre-existing condition exclusions as a result of either genetic information or for pregnancy. In addition, exclusion periods are not permitted in the case of newborn babies, newly adopted children or children placed for adoption.
In general, pre-existing condition exclusion periods are only permitted for conditions that are diagnosed within the 6 months before joining a group scheme for which you have been given (or been recommended to have) treatment. This period is generally called the 'look back' period.
Wherever an exclusion period is required it may not normally be longer than 12 months and you must be credited for any previous continuous creditable coverage. Here cover is classed as continuous as long as it is not interrupted by a break of more than 63 consecutive days. Almost all government sponsored and private health coverage is classed as creditable and this will include such things as Medicare, individual health insurance, foreign national coverage, VA coverage, Indian health insurance, military health coverage, Medicaid, student health insurance and more.
Where an employer imposes a waiting period for employees to join a plan, or an HMO imposes a similar affiliation period, these may not be counted in determining any break in continuous coverage. In addition, pre-existing condition exclusion periods must take into account the waiting or affiliation period with the exclusion period starting on the same day as the waiting or affiliation period.
If you are moving between group plans then your new plan administrator may examine your previous plan to calculate any credit towards a pre-existing condition exclusion period for your new plan. This may mean for example that if your new plan offers cover that was not provided under your previous plan then exclusion periods may be required 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 must be given appropriate written notice of any exclusion period and the group plan administrator must assist you in obtaining a certificate of creditable coverage for your old plan if you want him to do so.
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