Can Group Health Schemes Refuse Cover Because of A Pre-Existing Medical Condition?

When it comes to group health schemes there is generally confusion because, although a lot of people contend that group plans are not allowed to exclude you from cover because of your present health or your medical history, other people contend that they are permitted to refuse cover in the case of pre-existing conditions.

It is in fact true that you may not be denied membership of a group plan solely as a result of you present health, which includes any disability, or because of your past medical history.

Having said this, employers and insurance companies 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 to establish whether you have a previous history of the condition which is the subject of your claim.

When a pre-existing condition is either reported or discovered the insurance company or employer cannot simply refuse you coverage under a group plan but is allowed to impose an exclusion period for coverage of that particular pre-existing condition. This said, there are federal and state laws which govern the exclusions which employers and insurance companies can place on their group schemes.

Group health schemes are not permitted to impose pre-existing condition exclusions on the basis of either genetic information or for pregnancy. Further, 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 scheme and for which you have had (or been recommended to receive) treatment. This 6 month period is frequently known as the 'look back' period.

If a pre-existing condition exclusion period is required it may not generally be longer than 12 months and you have to receive credit for any previous continuous creditable coverage. In this case cover is classed as continuous where it has not been interrupted by a break in excess of 63 consecutive days. Virtually all private and government sponsored health coverage is considered to be creditable and this will include such things as Medicare, Indian health insurance, Medicaid, military health coverage, VA coverage, foreign national coverage, individual health insurance, student health insurance and more.

Where an employer imposes a waiting period for individuals to enter a scheme, or an HMO imposes a similar affiliation period, these may not be counted in determining a break in continuous coverage. Further, pre-existing condition exclusion periods must take into account the waiting or affiliation period with the exclusion period beginning on the first day of the waiting or affiliation period.

When moving between group schemes then the new scheme administrator is allowed to look at your old 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 which was not provided under the previous plan then exclusion periods may be required for pre-existing conditions which were not covered before but which are covered under the new plan.

One more point to note is that you must be given appropriate written notice of any exclusion period and the group scheme administrator must help you to obtain a certificate of creditable coverage from your old plan if you wish him to do so.

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