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
New York lawmakers included a prudent layperson standard in an emergency care coverage law adopted in 1997.
In New York, the authors of the circular letter write, consumers who suffer severe, sudden pain have a right to seek reimbursement for emergency care if they believe their conditions might lead to serious disfigurement, serious dysfunction of body parts or serious impairment to bodily functions.
Patients also have the right to seek reimbursement for emergency care if they believe their conditions could place themselves or others in “serious jeopardy,” the regulators write.
“Although the diagnosis code may be used to approve coverage of emergency services, its use as the basis for denial of coverage is improper,” the regulators write.
The regulators concede that they have been letting carriers include post-treatment notification requirements in health insurance policies and subscriber contracts, to help carriers coordinate follow-up care and assure access to appropriate services.
Regulators have decided to eliminate notice requirements, because New York insurance laws require carriers to cover any emergency care that meets that prudent layperson law and make no mention of exceptions for patients who violate notice requirements, the regulators write.