Individual Insurance Market Rules in West Virginia
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- Can insurance companies deny me coverage?
In West Virginia insurance companies cannot deny you coverage during certain time periods throughout the year. HMOs with greater than 5 years in the market or with enrollment greater than 50,000, cannot deny coverage during an annual 30 day open enrollment period.
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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 West Virginia. 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 West Virginia. 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 West Virginia insurance companies cannot put an elimination rider on your policy 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 West Virginia. 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 West Virginia. If you make a claim for health care services during the first 12 months of coverage, the insurance company can search your medical history 24 months (2 years) 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 West Virginia. 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 person can appeal any denial when services are deemed not medically necessary. The appeal must be filed with the Insurance Commissioner within 60 days of notice; the process is free.
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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 West Virginia. 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 West Virginia Insurance Commissioner.
