Individual Insurance Market Rules in New York
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- Can insurance companies deny me coverage?
Insurance companies cannot deny you coverage in New York, all individual health insurance policies must be offered to all residents on a guaranteed issue basis year-round. This means that insurance companies are required to sell coverage to everyone who applies.
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- Can insurance companies charge me more than other people for the same policy?
Insurance companies cannot charge you more than other people for the same policy in New York. New York uses “pure community rating,” which means that rates cannot differ due to health status, age or gender.
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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 New York. Insurance companies cannot 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 (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 New York. 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 limited in their ability to search your medical records for an excuse to deny you coverage for needed care in New York. If you make a claim for health care services during the first 12 months 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.
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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 New York. 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?
A member of any health carrier can appeal any adverse determination to an outside entity in New York. You can file an appeal to the Insurance Commissioner. There is a maximum $50 fee for the service and an appeal must be filed within 45 days.
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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 that causes you or a loved-one harm in New York. 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 New York State Insurance Department.
