Individual Insurance Market Rules in Arizona

State Rule Good, Bad or Ugly?
Getting Affordable Coverage

  • Can insurance companies deny me coverage?
    • Insurance companies can deny you coverage in Arizona. Insurance companies are not required to sell coverage to everyone who applies. That means they can deny you coverage because of anything they find objectionable in your health history.


Ugly

  • Can insurance companies charge me more than other people for the same policy?
    • Insurance companies can charge you more than other people for the same policy in Arizona. If an insurance company chooses to sell you a policy it can charge you more for the same policy if it believes you pose a higher risk of costing it money, including if you have a pre-existing condition, are older, or are a woman of childbearing age.


Ugly

  • Can insurance companies exclude coverage of my pre-existing condition?
    • Insurance companies can permanently exclude coverage of your pre-existing condition in Arizona. Insurance companies can permanently exclude from coverage any health problems you disclose, or they find in your medical records, at the time of application by an amendment to the individual health insurance contract. This is called an “elimination rider.” In Arizona insurance companies can put an elimination rider on your policy even if you previously had insurance that covered that condition.


Ugly

  • Can insurance companies make up their own definition of a pre-existing condition?
    • Insurance companies can make up their own definition of a pre-existing condition in Arizona. Insurance companies can define a pre-existing condition however they want. They can claim something is a pre-existing condition even if you had no symptoms of it and never sought treatment for it. Then they can deny payment for treatments related to those “pre-existing” conditions.


Ugly

Getting the Care You Need

  • Can insurance companies accept my application for coverage and later search my medical records for an excuse to deny me coverage for needed care?
    • Insurance companies can accept your application for coverage and later search your medical records for an excuse to deny you coverage for needed care in Arizona. Any time you make a claim for health care services, the insurance company can search your medical history as far back as it wants looking for evidence that your current health problem was pre-existing. If the insurance company finds any such evidence, it can deny you coverage for that condition.


Ugly

  • Can insurance companies pay their doctors incentives to provide me with less care?
    • Insurance companies cannot pay their doctors incentives to provide you with less care in Arizona. An insurance company cannot pay health care providers incentives to withhold covered care.


Good

  • Can I appeal an insurance company’s denial of care to an outside entity?
    • You can appeal an insurance company’s denial of care to an outside entity if you are in any health plan in Arizona. If you are a member of any type of health plan you can file an appeal for any denial of claims or benefits to the Director of the Insurance Department. The appeal is free. You must file an appeal within 30 days of written notice of final denial from your health plan.


Good

  • Can I sue my insurance company if it denies medically necessary care that causes me or a loved-one harm?
    • You can sue your insurance company if it denies medically necessary care that causes you or a loved-one harm in Arizona. You can sue an insurance company for harm that may have resulted from its denial of coverage or benefits.


Good

SOURCE: Kaiser Family Foundation State Health Facts, 2007

- To learn about all your rights and protections in the individual insurance market, contact the Arizona Department of Insurance.

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