Health insurance companies can be vicious, especially now that they too need to strangle with the global economic crisis. The possibility is made even clearer by the records of complaints against insurers. Anyone can be a victim and it can happen with group, individual, group, and job-based health insurance plans so federal and state laws provide the legal protections.
We must never forget though, that these very same laws protect insurance companies as well. Employer-sponsored group health plan rules are basically the same in different states for it is the federal government that set it. Additional state laws may modify protections, though. Non-discrimination protection, for instance, says that no employer should base eligibility for group health plan on health status.
This also applies to benefits offered but not with offering different coverage. As with special enrollment period, 30 days should be given the employee to enroll or change health plan group. Employers cannot refuse or charge more an individual of a group plan because of pre-existing condition but can impose temporary exclusion period of not more that 12 months, but do not apply to pregnancy, newborns, and genetic information.
The waiting period must be counted along with the pre-ex. Receiving medical treatment within 6 months prior to enrolling in the group health plan can limit coverage. If previously enrolled to a group plan without 63 consecutive days break, a certificate of creditable coverage can lessen pre-ex period. In situations where claims were mistakably not granted with employer-sponsored group plans, internal appeals process or independent external reviewer can help.
On the other hand, disputes with individual health insurance, the agent often gives the aid besides the internal appeals process and independent external reviewer. But because insurance companies pay agents, be wary of any fraudulent act and keep the state insurance department at hand. Individual health insurance plans greatly vary in different states because they regulate them, making employer-sponsored plans offer more protections. One can be turned down of any plan because of health status or pre-existing condition.
Other states though, offer guaranteed issue, which means individual health plans are required to sell to all, regardless of health status. Coverage is strictly limited with individual plans, and may actually exclude benefits such as maternity and prescription drugs. Many impose high annual deductibles, while in some states, coverage of basic benefits are a standard policy. Riders and exclusions may be offered depending on the state rules. Insurers may investigate past medical records and decided whether you have pre-existing conditions.
To know whether or not this applies to you and to how long an investigation can be done, check on the state insurance department. Premium costs also vary from state to state so know the rates. You may be living where there is community rating, wherein health status isn’t a determining factor of how much the premium is. Durational rating with which premium increases at renewal may apply in your place instead of the first mentioned.
Also know that there are states that allow re-underwriting wherein premiums increase at renewal when you got sick. With association-sold health insurance, rules for non-discrimination, special enrollment periods, limits on pre-existing condition exclusion periods, and credit coverage should not be mistaken to be the same with individual and employer-sponsored health plans.
Differences may vary from state to state. Before deciding to join any large group, know the state protections that apply such as whether or not a certain policy apply when you are out your state or within the place where you live. Insurers with complaints outnumbering others should definitely not be included in your list of options.
