Individual Insurance Market Rules in Washington
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- Can insurance companies deny me coverage?
Insurance companies can deny you coverage in Washington. 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. But, insurers in the individual market must give coverage to applicants achieving a minimum score on a state mandated health status questionnaire (or health screen). Those applicants, not eligible for guaranteed issue plans, are referred to the high risk pool.
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- Can insurance companies charge me more than other people for the same policy?
In Washington insurance companies are limited in how they can adjust rates for different people. Washington 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 Washington. 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 Washington. Insurance companies can consider something a pre-existing condition if the person received medical advice, diagnosis, care or treatment for that condition prior to enrollment in the plan. They can also consider a condition pre-existing if it was never diagnosed but you had symptoms for which an ordinary prudent person would have sought medical advice, care or treatment. This is called a “prudent person 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 Washington. If you make a claim for health care services during the first 9 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. 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 Washington. 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?
In Washington, people can appeal any decision to deny, modify, reduce, or terminate health care services. The appeal must be filed with the Commissioner of Insurance and is free; there is also no time limit.
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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 Washington. 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 Washington Commissioner of Insurance.
