When it comes to group health schemes there is usually confusion because, although a lot of people contend that group plans cannot refuse you cover because of your present health or your previous history, other people maintain that they are permitted to refuse cover for pre-existing conditions.
The reality is that you cannot be refused membership of a group plan solely as a result of you present medical state, which includes any disability, or as a result of your prior medical history.
Having said this, insurers and employers are permitted 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 in order to see if you have any previous history of the condition which is the subject of your claim.
Where a pre-existing condition is reported or found the insurer or employer may not simply refuse you coverage under a group plan but is permitted to impose an exclusion period for coverage of that particular pre-existing condition. However, there are federal and state laws which limit the exclusions which insurers and employers can place on their group schemes.
Group health schemes are not permitted to apply pre-existing condition exclusions as a result of genetic information or for pregnancy. Further, exclusion periods are not permitted for newborns, newly adopted children or children who are placed for adoption.
Generally speaking, pre-existing condition exclusion periods can only be imposed for conditions which are diagnosed within the 6 months prior to 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.
Whenever a pre-existing condition exclusion period is required it cannot generally exceed 12 months and you have to be credited for any previous continuous creditable coverage. Here cover is classed as continuous where it is not interrupted by a break of more than 63 days in a row. Virtually all private and government sponsored health coverage is considered to be creditable and this will include such things as Medicare, Indian health insurance, student health insurance, VA coverage, foreign national coverage, individual health insurance, Medicaid, military health coverage and much more.
When an employer requires a waiting period for individuals to enter 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 into account the waiting or affiliation period with the pre-existing condition exclusion period beginning on the first day of the waiting or affiliation period.
If you are moving from one group scheme to another then the new plan administrator is permitted to look at your old plan to work out any credit entitlement towards an exclusion period for your new plan. This may mean for instance that if the new plan offers cover which was not provided under the old plan then exclusion periods can be required for pre-existing conditions which were not covered before but which are covered under the new plan.
One final point to note is that you must be given appropriate written notice of any pre-existing condition exclusion period and the group scheme administrator must help you to obtain a certificate of creditable coverage for your old plan if you wish him to do so.
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