Individual Insurance Market Rules in Tennessee
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- Can insurance companies deny me coverage?
Insurance companies can deny you coverage in Tennessee. 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 Tennessee, 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?
Insurance companies can charge you more than other people for the same policy in Tennessee. 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 Tennessee. 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 Tennessee 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 Tennessee. 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 Tennessee. If you make a claim for health care services during the first 24 months (two years) of coverage, the insurance company can search your entire medical history 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 Tennessee. 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?
Any member of an HMO can appeal any denial based on a determination that the service was not medically necessary to an outside entity in Tennessee. An appeal must be filed with the Insurance Commissioner within 60 days of notification and there is a $50 fee.
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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 Tennessee. 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 Tennessee Department of Commerce and Insurance.
