There is generally confusion when considering group health schemes because, while a lot of people contend that group health plans are not allowed to exclude you from cover because of your current health or your previous history, other people claim that they are allowed to refuse cover when it comes to pre-existing conditions.

It is certainly true that you may not be refused membership of a group health plan solely because of you current health, including any disability which you might be suffering from, or because of your prior medical history.

However, insurance companies and employers are entitled to question you about any pre-existing medical conditions at the time of enrollment or, if you make a claim during your first year of cover, to look back in order to establish whether you have any previous history of the condition which is the subject of your claim.

Whenever a pre-existing condition is either reported or unearthed the insurance company or employer may not simply deny you cover under a group plan but is permitted to require an exclusion period for cover of that particular pre-existing condition. Having said this, there are federal and state laws which regulate the exclusions which insurance companies and employers can place on their group health schemes.

Group health schemes are not allowed to impose pre-existing condition exclusion periods as a result of either pregnancy or genetic information. Additionally, exclusion periods are not permitted for newborns, newly adopted children or children placed for adoption.

In general terms, pre-existing condition exclusion periods are only permitted for conditions which are diagnosed within the 6 months before joining a group health scheme for which you have received (or been recommended to have) treatment. This 6 month period is frequently called the 'look back' period.

Whenever a pre-existing condition exclusion period is required it may not usually be longer than 12 months and you have to be credited for any previous continuous creditable coverage. Here cover is said to be continuous when it has not been interrupted by a break of more than 63 consecutive days. Virtually all government sponsored and private health coverage is classed as creditable and this will include such things as Medicare, military health coverage, foreign national coverage, individual health insurance, Indian health insurance, VA coverage, Medicaid, student health insurance and more.

Where an employer imposes a waiting period for individuals to enter a plan, or an HMO imposes a similar affiliation period, these may not be counted in calculating any break in continuous coverage. Additionally, pre-existing condition exclusion periods 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 between group plans then the new plan administrator is permitted to look at your previous plan to work out any credit entitlement towards an exclusion period for your new plan. This could mean for instance that if your new plan provides cover which was not provided under the old plan then exclusion periods may be required for pre-existing conditions which were not covered before but which are covered under the new plan.

One more point to note is that you must be given appropriate written notice of any pre-existing condition exclusion period and the group plan administrator has to help you to obtain a certificate of creditable coverage for your previous plan if you want him to do so.