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Atlantis Outpatient Centers

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Pre-existing Condition Limitation

A Pre-existing Condition is a condition (whether physical or mental), regardless of the cause of the condition for which medical advice; diagnosis, care or treatment was recommended or received within the 6 - (six) month period ending on the Covered Person’s Enrollment Date. Genetic information will not be used in the absence of a diagnosis of the condition related to such information.

The exclusion of coverage for a Pre-Existing Condition is for an 11 (eleven)-month period following the Covered Person’s Enrollment Date. The Pre-existing Condition limitation does not apply to Members of Large Groups.

In applying the Pre-existing Condition, Atlantis will give credit for the time a person was covered under previous health insurance plans or policies or employer provided health benefits arrangements, whether insured or self-insured, if the previous coverage was continuous to a date not more than sixty-three (63) days prior to the Enrollment Date of this new coverage. Credit will be applied without regard to the specific benefits of the Creditable Coverage. In the case of previous HMO coverage, any affiliation period prior to that coverage becoming effective will also be credited.

Any Member whose prior coverage lapsed for more than a period of 63 consecutive days will be subject to the full extent of the Pre-Existing Condition Limitation.

The Pre-existing Condition exclusion does not apply in the case of:

1. An individual who, as of the last day of the 30-day period beginning with the date of birth, is covered under Creditable Coverage;

2. A child who is adopted or placed for adoption before attaining 18-years of age and who is, as of the last day of the 30-day period beginning on the date of the adoption or placement for adoption, is covered under Creditable Coverage;

3. Pregnancy; or

4. Members of large groups (more than fifty Members).

See Section III - “Definitions- Creditable Coverage and Large Group”.

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