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The New York State Insurance Department is banning emergency care notice requirements in state-regulated health insurance policies and subscriber contracts.

Carriers can ask insureds to tell them about emergency room visits, and deny coverage when insureds go for symptoms that would not lead a “prudent layperson” to seek emergency care, the department says.

But a carrier must base 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 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. The law gives consumers who suffer severe, sudden pain the right to seek reimbursement for emergency care if they believe their conditions might lead to serious harm to themselves or others.

The New York department has been letting carriers include post-treatment notification requirements in health insurance policies, to help the carriers coordinate follow-up care, but officials say they have now decided that the emergency coverage law leaves no room for mandatory notice requirements.


Reproduced from National Underwriter Life & Health/Financial Services Edition, February 4, 2002. Copyright 2002 by The National Underwriter Company in the serial publication. All rights reserved.Copyright in this article as an independent work may be held by the author.


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