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There is often confusion when looking at group health insurance plans because, although many people maintain that group insurance plans are not allowed to refuse you cover on the basis of your present health or your medical history, others say that they are permitted to refuse cover when it comes to pre-existing medical conditions. The reality is that you cannot be refused membership of a group insurance plan solely because of you present health, which includes any disability that you might be suffering from, or because of your past medical history. However, both employers and insurance companies are permitted to question you about any pre-existing medical conditions when you join a scheme or, if you make a claim during your first year of cover, to look back to establish whether you have any prior history of the condition which gives rise to the claim. Whenever a pre-existing condition is either reported or found the employer or insurer may not simply deny you cover under a group plan but may impose an exclusion period for cover of that specific pre-existing condition. This said, there are both federal and state laws that regulate the exclusions that employers and insurance companies may place on their group plans. Group health insurance plans are not permitted to impose pre-existing condition exclusion periods on the basis of either pregnancy or genetic information. Further, exclusions are not permitted for newborn babies, newly adopted children and children who are placed for adoption. In general terms, pre-existing condition exclusions are only permitted for conditions that are diagnosed within the 6 months prior to joining a group scheme for which you have had (or been recommended to receive) treatment. This 6 month period is often referred to as the 'look back' period. When a pre-existing condition exclusion period is imposed it cannot generally be longer than 12 months and you must receive credit for any previous continuous creditable coverage. In this case cover is classed as continuous as long as it is not interrupted by a break of more than 63 days in a row. The majority of government sponsored and private health coverage is considered to be creditable and this will include such things as Medicare, student health insurance, individual health insurance, Indian health insurance, Medicaid, VA coverage, military health coverage, foreign national coverage and much more. Where 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. In addition, pre-existing condition exclusion periods have to take account of 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 between group schemes then your new plan administrator may examine your previous plan to calculate any credit entitlement towards a pre-existing condition exclusion period for your new plan. This might mean for example that if the new plan offers cover that was not provided under your previous plan then exclusion periods may be imposed for pre-existing conditions that were not covered before but that are covered under your new plan. One more point worth noting is that you have to be given appropriate notice of any pre-existing condition exclusion period in writing and the group scheme administrator has to help you to obtain a certificate of creditable coverage for your previous plan if you wish him to do so.
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