When looking at group health insurance schemes there is frequently confusion because, while some people contend that group insurance plans may not exclude you from cover because of your present health or your prior medical history, others maintain that they are allowed to refuse cover for pre-existing conditions. It is in fact the case that you cannot be denied membership of a group insurance plan solely as a result of you present medical state, including any disability, or as a result of your past medical history. Nonetheless, employers and insurance companies are permitted to ask you if you have any pre-existing medical conditions on enrollment or, if you make a claim during your first year of coverage, to look back to see if you have any past history of the condition which is the subject of your claim. If a pre-existing condition is reported or found the employer or insurer may not simply deny you coverage under a group plan but may impose 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 employers and insurance companies are permitted to place on their group schemes. Group health insurance schemes are not allowed to apply pre-existing condition exclusion periods because of pregnancy or genetic information. Additionally, exclusion periods are not allowed in the case of newborns, newly adopted children or children who are placed for adoption. In general terms, pre-existing condition exclusion periods are only allowed for conditions that are diagnosed within the 6 months before joining a group scheme for which you have been given (or been recommended to receive) treatment. This 6 month period is generally called the 'look back' period. Whenever a pre-existing condition exclusion period is imposed it cannot generally exceed 12 months and you must receive credit for any previous continuous creditable coverage. In this case cover is classed as continuous where it is not interrupted by a break of more than 63 consecutive days. Virtually all private and government sponsored health coverage is classed as creditable and this will include such things as Medicare, military health coverage, foreign national coverage, Medicaid, student health insurance, individual health insurance, VA coverage, Indian health insurance and more. If an employer requires a waiting period for people to join a scheme, or an HMO requires a similar affiliation period, these cannot be counted in determining any break in continuous coverage. Further, any pre-existing condition exclusion period must take account of the waiting or affiliation period with the exclusion period starting on the first day of the waiting or affiliation period. If you are moving from one group scheme to another then the administrator of the new plan may examine your previous plan to calculate any credit towards a pre-existing condition exclusion period for your new plan. This could mean for instance that if the new plan provides cover that was not provided under the previous plan then exclusion periods can be imposed for pre-existing conditions that were not covered before but that are covered under the new plan. One more point to note is that you have to be given appropriate written notice of any exclusion period and the group scheme administrator is obliged to assist you in obtaining a certificate of creditable coverage from your previous plan if you wish him to do so.
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