Can Group Health Insurance Plans Refuse Coverage For Pre-Existing Medical Conditions?
Health Insurance:
When looking at group health plans there is usually confusion because, although many people maintain that group health plans are not permitted to refuse you cover as a result of your present health or your prior history, other people argue that they can in fact refuse cover in the case of pre-existing conditions.
The reality is that you cannot be denied membership of a group health plan solely as a result of you present health, which includes any disability that you might be suffering from, or as a result of your previous medical history.
However, 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 in order to establish whether you have any past history of the condition which gives rise to the claim.
When a pre-existing condition is either reported or unearthed the insurer or employer cannot simply refuse you coverage under a group plan but may impose an exclusion period for coverage of that particular pre-existing condition. However, there are federal and state laws that govern the exclusions that employers and insurance companies can place on their group health plans.
Group health plans are not allowed to impose pre-existing condition exclusion periods as a result of either genetic information or for pregnancy. In addition, exclusions are not allowed in the case of newborn babies, newly adopted children or children placed for adoption.
In general terms, pre-existing condition exclusions are only allowed for conditions that are diagnosed within the 6 months before joining a group health scheme for which you have received (or been recommended to receive) treatment. This period is frequently called the 'look back' period.
Wherever a pre-existing condition exclusion period is imposed it cannot normally be longer than 12 months and you must be credited for any previous continuous creditable coverage. Here cover is considered to be continuous as long as it has not been interrupted by a break in excess of 63 consecutive days. The majority of private and government sponsored health coverage is considered to be creditable and this will include such things as Medicare, Medicaid, foreign national coverage, Indian health insurance, VA coverage, student health insurance, individual health insurance, military health coverage and much more.
When an employer imposes a waiting period for employees to enter a plan, or an HMO imposes a similar affiliation period, these cannot be counted in calculating any break in continuous coverage. Furthermore, pre-existing condition exclusion periods must take account of the waiting or affiliation period with the exclusion period beginning on the same day as the waiting or affiliation period.
If you are moving from one group plan to another then the administrator of the new scheme may examine your old plan to work out any credit entitlement towards a pre-existing condition exclusion period for your new plan. This might mean for example that if your new plan provides cover that was not provided under the previous plan then exclusion periods may be imposed for pre-existing conditions that were not formerly covered but that are covered under the new plan.
One final point worth noting is that you must be given appropriate notice of any exclusion period in writing and the group plan administrator is obliged to assist you in obtaining a certificate of creditable coverage from your former plan if you wish him to do so.
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