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How does a pre-existing condition exclusion period work?

A pre-existing condition exclusion period is a period of time during which your insurer is not obligated to pay claims related to your pre-existing condition.

A pre-existing condition is a medical condition for which medical advice, diagnosis, care, or treatment was recommended or received within the 6-month period before your enrollment date in an employer's group health plan.

If you had a medical condition in the past, but have not received any medical advice, diagnosis, care or treatment (or any recommendation to seek such care) within the 6 months prior to your enrollment date in the plan, your old condition cannot be considered a pre-existing condition. Moreover, pregnancy cannot ever be considered a pre-existing condition under employer-sponsored group health plans.

Your enrollment date is your first day of coverage, or if there is a waiting period to get into the plan, the first day of the waiting period.

If you are in an employer-sponsored group health plan, your plan must notify you if it has a pre-existing condition exclusion period (and can only exclude coverage for a pre-existing condition after you have been notified). The plan must also notify you of your right to show that you have prior creditable coverage to reduce the pre-existing condition exclusion period.

In most states, the rules governing pre-existing condition exclusion periods for individual health insurance policies are very different from group health plan rules.

In most states, individual insurance policies can turn you down for coverage altogether if you have a pre-existing condition. Or, your policy might permanently exclude your pre-existing condition. For more information about pre-existing condition exclusion periods, please refer to your state consumer guide.

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Important: This content reflects information from various individuals and organizations and may offer alternative or opposing points of view. It should not be used for medical advice, diagnosis or treatment. As always, you should consult with your healthcare provider about your specific health needs.