NU Online News Service, Jan. 29, 2:38 p.m. – The New York State Insurance Department is banning emergency care notice requirements in state-regulated health insurance policies and subscriber requirements.
Carriers can ask plan members to notify them about visits to the emergency room, and deny coverage when members go to the emergency room for symptoms that would not lead a “prudent layperson” to seek emergency care, the department says.
But a carrier must base benefits denial decisions on the symptoms, not the diagnosis, and it cannot use violations of notice requirements as a reason to deny or reduce benefits, the department says.
“To deny or reduce benefits on this basis would be inconsistent with the Insurance Law,” department officials write in Circular Letter Number 1 (2002).
The department lists the authors as Deborah Kozemko, a department attorney, and Thomas Zyra and Charles Henricks, the co-chiefs of the department Health Bureau.
The department sent the letter to all health insurers, nonprofit health insurers and health maintenance organizations licensed to sell coverage in New York state.
The department also posted the letter on its Web site, at http://www.ins.state.ny.us/cl02_01.htm