Individual Insurance Market Rules in Oregon
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- Can insurance companies deny me coverage?
Insurance companies can deny you coverage in Oregon. 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. However, in Oregon, individual market insurance companies must sell standardized high-risk pool policies to anyone who has a pre-existing condition that makes him/her ineligible for a regular insurance policy.
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- Can insurance companies charge me more than other people for the same policy?
In Oregon insurance companies are limited in how they can adjust rates for different people. Oregon uses an “adjusted community rating,” which means that premiums can be adjusted for age or other factors but there are limits.
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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 Oregon. 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 Orgeon. 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 can accept your application for coverage and later search your medical records for an excuse to deny you coverage for needed care in Oregon. 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 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?
Insurance companies can pay their doctors incentives to provide you with less care in Oregon. An insurance company can 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?
Anyone can appeal any denial decision based on medical necessity. The appeal process is free but must be filed within 180 days of receipt of the decision.
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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 Oregon. 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 Oregon Insurance Division.
