Individual Insurance Market Rules in Michigan
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- Can insurance companies deny me coverage?
Insurance companies can deny you coverage in Michigan ,but HMOs, after 24 months in existence, are required to guarantee issue to a limited number of applicants during one, 30 day open enrollment per year. During this time an HMO cannot deny you coverage.
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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 Michigan. 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 cannot permanently exclude coverage of your pre-existing condition in Michigan. Insurance companies cannot permanently exclude from coverage any healthproblems you disclose, or they find in your medical records, at the time of application by an amendment to the individual health insurance contract (called an “elimination rider”).
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- Can insurance companies make up their own definition of a pre-existing condition?
Insurance companies cannot make up their own definition of a pre-existing condition in Michigan. Insurance companies can only consider something a pre-existing condition if the person actually received medical advice, diagnosis, care or treatment for that condition prior to enrollment in the plan. This is called an "objective standard."
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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 are only allowed to search your medical records for up to 6 months back for an excuse to deny you coverage for needed care for claims you submit during the first 12 months of coverage.
If you make a claim for health care services during the first 12 months
(one year) of coverage, the insurance company can search your medical
history dating back 6 months prior to the purchase of your policy
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?
No, insurance companies cannot give incentives to your doctors to provide less care.
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?
Yes, you can appeal any insurance company's denail of care to an outside entity.
You can file an appeal for any denial of service to the State Insurance Commissioner. The process is free. You must file an appeal
within 60 days of final notice of denial by a health plan.
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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 cannot sue your insurance company if it denies medically necessary care.
You cannot 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 Michigan Insurance Bureau.
