Will an Insurance Carrier Deny Certain Employees Coverage under a Group Health Insurance Plan?

A group health insurance plan is one of the products that an insurance company offers. It is said to be one of the convenient ways of obtaining insurance, and brings in mutual benefits for both the insurance company and the group with its individual members who avail of it.

Although it is usually the companies or small businesses which offer group health insurance plans to its employees, it is not limited to such. Different organizations, clubs, special interest groups, religious groups, chambers of commerce, and trade associations can also avail of it.

A group health insurance plan is beneficial on the part of the insurance company offering it since it attracts more people to avail of the plan. Thus, this means more profit. On the part of the group availing it, a group health insurance plan enables them to provide protection to its individual members. And for its members, being in a group plan spares them from shouldering much of the insurance premiums, since many employers cover part or all of it.

However, being in a group health insurance plan doesn’t guarantee that all of the group’s members can avail of the offered plan. The insurance company still has to evaluate the individual members who are part of the group, and they still have the power to approve or deny the application for coverage of individuals.

The group health insurance plan may exclude individuals who have a pre-existing medical condition, or those who have been to a medical professional for consultation or treatment within the last six months immediately before the group’s enrollment to the plan. If there is a pre-existing condition, the insurance company will not pay for claims made for any of the individual’s consultation, treatment or tests related to it. Such examples of chronic conditions that exclude a person from coverage within the group health insurance plan are cancer, heart-disease, and diabetes. A person who has carpal tunnel syndrome may also be excluded from claims related to that disorder.

There are special cases, however, when exemptions are made, and certain individuals may still be granted inclusion to a group health insurance plan. For example, a pregnant woman cannot be denied medical coverage, even though she doesn’t have health insurance in place before her first date of employment. Coverage is also given for newborn babies, or even adopted children under the age of 18. The newborn must be enrolled in the health insurance plan within 30 days of birth to qualify for the coverage.

A person may also not be denied coverage because of a genetic predisposition to certain medical conditions. For example, if through genetic testing it was revealed that a person is more likely to develop cancer within a certain working environment, then that person cannot be denied medical insurance coverage.

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 certain pre-existing health conditions. Under this provision a health insurance plan is only allowed to exclude an applicant for pre-existing conditions which 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 various cases, the exclusion period is limited to twelve months. However, it may be as along as eighteen months for people who are enrolled late in the health insurance plan. Specific health plans may have a shorter period of exclusion, and new members of the plan may not be required to go through a waiting period at all.