When do individual health insurers have to sell me a policy?

In Connecticut, your ability to buy individual health insurance may depend on your health status. There are certain circumstances, however, when you must be allowed to buy individual health insurance policy.

· In general, insurers that sell individual health insurance policies in Connecticut are free to turn you down because of your health status and other factors. When applying for an individual health insurance policy, you may be asked questions about health conditions you have now or had in the past. Depending on your health status, insurers might refuse to sell you coverage or offer to sell you a policy that has special limitations on what it covers.

However, under no circumstance can you be turned down, charged more or face a pre-existing exclusion period because of your genetic information. Genetic information includes the results of a genetic test and your family history of health conditions.

· You may be eligible to buy an individual policy through the Connecticut Health Reinsurance Association (HRA), the state’s high risk pool, if you are a resident and over the age of 19 and under the age of 65.

· In Connecticut, newborns and adopted children are automatically covered under the parents’ fully insured health policy for the first 31 days, if the policy covers dependents. The insurer may require the parent to enroll the child within the 31 days in order to continue coverage beyond the 31 days.

· If you have a disabled child, that child may remain covered under your individual health insurance policy after he or she reaches the age at which dependent coverage is usually terminated. To qualify, your son or daughter must be incapable of self-support because of mental or physical disability and must be chiefly dependent on the policy-holder for support. Proof of incapacity must be furnished within 31 days of reaching the time limit and may be required periodically thereafter.

What will my individual health policy cover?

· It depends on what you buy.Connecticut does not require individual health insurers in the individual market to sell standardized policies. Insurers can design different policies and you will have to read and compare them carefully. However, Connecticut does require all health plans to cover certain benefits — such as prostate cancer screening and diabetes testing and treatment. Check with the Connecticut Department of Insurance for more information about mandated benefits.

What about coverage for my pre-existing condition?

· Individual health insurers can impose elimination riders. This is an amendment to your health insurance policy that permanently excludes coverage for a health condition or even an entire body part or system.

· Individual insurers can also impose pre-existing condition exclusion period. Pre-existing condition exclusion periods cannot exceed 12 months. A pre-existing condition exclusion period are only those conditions for which you actually received (or were recommended to receive) a diagnosis, treatment or medical advice within the 12 months immediately before you joined the plan. This is called the objective standard. In Connecticut, pregnancy and genetic information cannot be considered a pre-existing condition in individual health insurance policies.

If a 12-month exclusion period is applied, you can get credit for any prior continuous creditable coverage you have had as long as you have not had a gap of 120 days or more between your old and new coverage.

· If you make a claim during the first two years of coverage, the insurer can look back 12 months from the time of your application to see if the claim is for a condition that would have been considered a pre-existing condition. If the insurer determines, using the objective standard, that the condition is a pre-existing condition, it can refuse to pay for expenses for that condition.

What can I be charged for an individual health insurance policy?

· If you have an expensive health condition, your individual health insurance premiums may be very high. The law doesn’t prohibit Connecticut health insurers from charging you more because of your health status and other factors, such as your age and gender.

Can my individual health insurance policy be canceled?

· Your coverage cannot be canceled if you get sick. This is called guaranteed renewability. You have this protection provided that you pay the premiums, do not defraud the company, and, in the case of managed care plans, continue to live in a managed care plan’s service area. However, your health coverage may be canceled if the insurer discontinues your health policy or withdraws from the individual market.

However if you make a claim during the first two years of coverage under your policy, the insurer might re-investigate information you provided during the application process to determine whether you made a misstatement.  If so, the insurer might try to take back your policy and void coverage altogether.

If you become involved in one of these “post-claims” investigations, be sure to call the Connecticut Insurance Department to learn more about your rights.

· Some insurance companies sell temporary health insurance policies. Temporary policies are not guaranteed renewable. They will only cover you for a limited time, such as six months. If you want to renew coverage under a temporary policy after it expires, you will have to apply for a new contract. There is no guarantee that coverage will be re-issued at all or at the same price.