Preexisting Condition Exclusions in Group Health Policies
Group health insurance policies often offer an affordable insurance solution for individuals who are expensive to insure by individual insurance standards. But that doesn’t mean that everyone’s preexisting conditions will automatically be covered by a group policy.
What is a preexisting condition?
A preexisting condition is any medical condition that you received treatment for before you were covered under the group plan. Generally, these are chronic health conditions, but can also include issues that stem from a one-time injury. For instance, if you hurt your back and were treated for it 3-months before joining a new group plan, then any future back-related problem that could have been caused by that initial injury could be considered a preexisting condition.
Because group health insurance policies are not individually underwritten, your individual health concerns are not considered to determine whether or not you are approved. Instead, new members are approved regardless of their health history but with coverage that may or may not extend to their preexisting conditions.
Avoiding Preexisting Condition Exclusions
In order to avoid getting caught in the preexisting condition conundrum you must have been covered by insurance for at least 3-12 months continuously prior to becoming part of the group insurance plan. In addition, you must have had no break in coverage longer than 63 days during that time. The amount of time you must have been covered before joining a group plan will vary depending on state. Another group policy, an individual policy and COBRA would all count as coverage.
If you do not meet these requirements then your preexisting condition will generally be excluded from coverage in the group plan for up to 12 months. This means that any claim your physician or a treatment center attempts to pass through to your insurance company for treatment of that condition will be declined and you must pay for it out of pocket.
If your health insurance plan has a deductible, the out-of-pocket amount that you pay for excluded preexisting conditions will not count toward your deductible or out-of-pocket maximum.
The best way to avoid having your preexisting conditions excluded the next time you join a group health insurance plan is to make sure you always remain covered by an insurance policy. Whether you choose COBRA coverage as you are between jobs or an individual policy, the important thing is simply to remain covered.
Learn more about medical insurance including fee-for-service and managed care. Contact us to get a free medical insurance quote at (219) 879-4581.