Health insurers in Connecticut can include discretionary clauses in policies and certificates but should use them only on rare occasions.
Connecticut Insurance Commissioner Thomas Sullivan gives that advice in Connecticut Bulletin HC-67.
A typical discretionary clause gives an individual or group insurance carrier discretion to determine eligibility for benefits and to interpret policy terms and provisions, Sullivan writes in the bulletin.
Discretionary clauses can be “used as reasonable and appropriate in unusual situations where there is no specific language in the policy,” Sullivan writes.
But Sullivan notes that the clauses cannot be used to deny a claim which otherwise ought to be paid.
The clauses also cannot be used to deny an insured’s right to appeal to the insurer, the right to use an external appeal process, or the right to go to court, Sullivan writes.