Under certain circumstances, an employee may be denied health insurance coverage by an employer. The group health insurance plan may exclude people who have been to a doctor for consultation or treatment for certain medical conditions within the six-month period immediately prior to enrolling.
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The conditions mentioned above may fall under the category of a pre-existing medical issue, and the insurance company will not pay for claims made for any consultation, tests or treatment that relate to it.
Examples of Pre-existing Medical Conditions
Examples of chronic conditions or injuries that a health insurance company may exclude a person from being covered under an employer-sponsored plan include cancer, heart disease and diabetes. A person who has carpal tunnel syndrome may also be excluded, at least from claims relating to that disorder.
Exemptions from Pre-existing Medical Condition Exclusion
There are also exemptions to the pre-existing medical conditions exclusions for work-related health insurance plans. A pregnant woman cannot be denied medical coverage, even if she didn’t have health insurance in place before the first date of employment.
Health measures needed for a newborn baby or an adopted child under the age of 18 are also covered. The newborn or newly-adopted child must be enrolled in the health insurance plan within 30 days of birth of the adoption to qualify for coverage.
A person may not be denied coverage under an employer health insurance plan because of a genetic predisposition to certain medical conditions. For example, if genetic testing reveals that a person is more likely to develop cancer than someone in the general population pool, he or she cannot be denied medical insurance coverage because they may develop this condition in the future.
HIPAA and Employer Health Plans
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) contains provisions that restrict an employer’s ability to exclude employees from a health insurance plan because of pre-existing health conditions. Under this law, an employer health insurance plan is only allowed to exclude an applicant for pre-existing conditions that were present during the previous six months.
HIPAA also helps plan members by limiting the time that a plan member’s coverage may be excluded under an employer health insurance plan. In many cases, the exclusion period is limited to 12 months, but it may be as long as 18 months for people who enrolled in the health insurance plan late. Certain health plans may have a shorter exclusion period, and new plan members may not be required to serve a waiting period at all.
The waiting period under HIPAA applies to medical conditions where the employee sought out medical advice or treatment during the six months prior to enrollment. If the employee had a medical condition but did not seek medical advice or undergo any treatment for it during that time, the employer health plan cannot consider it a pre-existing condition under the plan.
The fact that the employee could have been living with the medical condition for some time before enrolling in the employer-sponsored plan does not matter. Medical advice sought or given, or treatment received more than six months prior to enrollment does not matter for the purpose of determining whether it fits the definition of pre-existing condition or not.
Legislation and Employer’s Requirements
The legislation does not require employers to offer health insurance coverage to employees. It also does not require an employer to offer a health insurance plan that will cover any health conditions the employee has been diagnosed with, even if the employee was covered under a previous health insurance plan. Employers do have the right to impose a waiting period for coverage for pre-existing medical condition.
An employer may deny an employee health insurance coverage for a time due to a pre-existing health condition. During that time, the employee will be covered for health claims other than ones relating to the pre-existing condition. The waiting period that a new employee may have to serve varies from no waiting period at all to up to 18 months. Once the waiting period has been served, the employee will be covered for claims arising from the pre-existing condition.
For questions about the employer health insurance plan, an employee should read the plan booklet that explains what is covered. If the employee still has questions after reviewing the applicable portion of the benefits information, he or she should approach the plan administrator for more information about the plan provisions.
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