Individual Insurance Market Rules in Georgia
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- Can insurance companies deny me coverage?
Insurance companies can deny you coverage in Georgia. 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.
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- 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 Georgia. 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.
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- Can insurance companies exclude coverage of my pre-existing condition?
Insurance companies can permanently exclude coverage of your pre-existing condition in Georgia. 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 Georgia insurance companies can put an elimination rider on your policy even if you previously had insurance that covered that condition.
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- 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 Georgia. 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.
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- 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 Georgia. If you make a claim for health care services during the first 24 months (two years) of coverage, 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.
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- 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 Georgia. An insurance company cannot pay health care providers incentives to withhold covered care.
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- 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 managed care plan in Georgia. If you are a member of a managed care organization, like an HMO, you can file an appeal for any denial of claims or benefits to the Health Planning Agency. The appeal is free and there is no time limit to file an appeal. However, your appeal must be for a claim of at least $500.
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- 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 Georgia. You can sue an insurance company for any harm that may have resulted from its denial of coverage or benefits.
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SOURCE: Kaiser Family Foundation State Health Facts, 2007
To learn about all your rights and protections in the individual insurance market, contact the Georgia Office of Insurance and Safety Fire Commissioner.
