Individual Insurance Market Rules in Pennsylvania
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- Can insurance companies deny me coverage?
Insurance companies can deny you coverage in Pennsylvania. 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. In Pennsylvania, individual market insurance companies do not have to sell standardized high-risk pool policies to anyone.
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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 Pennsylvania. 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 Pennsylvania. 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 Pennsylvania 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 cannot make up their own definition of a pre-existing condition in Pennsylvania. 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 Pennsylvania. 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 60 months (5 years) 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 cannot pay their doctors incentives to provide you with less care in Pennsylvania. 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?
In Pennsylvania only people in a managed care plan can appeal a denial of covered services. The process cannot cost more than $25 but must be filed within 15 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 cannot sue your insurance company if it denies medically necessary care that causes you or a loved-one harm in Pennsylvania. 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 Pennsylvania Insurance Department.
