There is often confusion when talking about group health schemes because, although some people contend that group health plans are not allowed to exclude you from cover on the basis of your present health or your previous medical history, other people contend that they are allowed to refuse cover for pre-existing medical conditions.

The truth is that you may not be refused membership of a group health plan solely because of you present health, which includes any disability that you may have, or as a result of your prior medical history.

This said, both insurance companies and employers are entitled to ask you if you have any pre-existing medical conditions when you join a scheme or, if you submit a claim in the first year of coverage, to look back to establish whether you have any previous history of the condition which gives rise to the claim.

Where a pre-existing condition is either reported or found the insurer or employer may not simply deny you coverage under a group plan but may require an exclusion period for coverage of that particular pre-existing condition. Having said this, there are both federal and state laws that govern the exclusions that insurance companies and employers are allowed to place on their group health schemes.

Group health schemes cannot impose pre-existing condition exclusions because of either pregnancy or genetic information. Additionally, exclusions are not allowed for newborn babies, newly adopted children and children who are placed for adoption.

In general, pre-existing condition exclusions can only be imposed for conditions that 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 6 month period is often known as the ‘look back’ period.

Wherever an exclusion period is imposed it may not normally exceed 12 months and you must be credited for any previous continuous creditable coverage. Here cover is classed as continuous where it has not been interrupted by a break of more than 63 consecutive days. Most private and government sponsored health coverage is considered to be creditable and this will include such things as Medicare, VA coverage, foreign national coverage, student health insurance, Medicaid, military health coverage, Indian health insurance, individual health insurance and more.

Where an employer requires a waiting period for people to enter a scheme, or an HMO requires a similar affiliation period, these may not be counted in calculating 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 beginning on the same day as the waiting or affiliation period.

If you are moving between group plans then the administrator of your new plan may look at your old plan to calculate any credit towards an exclusion period for your new plan. This could mean for instance that if the new plan offers cover that was not provided under your previous plan then exclusion periods can be imposed for pre-existing conditions that were not covered before but that are covered under your 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 is obliged to help you to obtain a certificate of creditable coverage for your old plan if you want him to do so.

By: Donald Saunders