Bill Text: DE HB216 | 2011-2012 | 146th General Assembly | Draft

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Bill Title: An Act To Amend Title 18 Of The Delaware Code Relating To Unfair Practices In The Business Of Insurance.

Spectrum: Bipartisan Bill

Status: (Introduced - Dead) 2011-06-29 - Introduced and Assigned to Economic Development/Banking/Insurance/Commerce Committee in House [HB216 Detail]

Download: Delaware-2011-HB216-Draft.html

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SPONSOR:	Rep. D. Short & Rep. B. Short;
	Reps. Briggs King, Hudson, Miro, Barbieri, Bolden, Kowalko, Scott; Sens. Booth, Ennis, Sokola

HOUSE OF REPRESENTATIVES

146th GENERAL ASSEMBLY

HOUSE BILL NO. 216

AN ACT TO AMEND TITLE 18 OF THE DELAWARE CODE RELATING TO UNFAIR PRACTICES IN THE BUSINESS OF INSURANCE.

BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF DELAWARE:

Section 1.Amend Chapter 23, Title 18, Delaware Code by adding a new section to read as follows:

"§2319.Not-medically-necessary error by insurer.

(a)                 A health insurer, health service corporation, or health maintenance organization may not unreasonably deny coverage for a medical procedure or test that the insurer decides is not medically necessary.It shall be presumed that such denial is unreasonable if an insured individual, who has followed the insurer's approval process including procedures for internal review, arbitration, and external review and have been denied, seeks medical care at his or her own expense after a denial of such coverage, and the procedure or test is proven to be medically necessary based upon the results of the procedure or test or upon the medical condition found.

(b)                 The Commissioner shall follow §2307 of this chapter to determine if subsection (a) of this section has been violated.

(c)                 If an insurer is found by the Commissioner to have unreasonably denied coverage pursuant to subsection (a) of this section, the insurer shall reimburse the insured for all expenses incurred and associated with the procedure or test at 100% of the incurred expenses.In addition, any out-of-pocket expenses, including but not limited to deductibles, co-pays, and coinsurance of the insured's healthcare benefit plan that would have been the responsibility of the insured must be reimbursed by the insurer to the insured individual.The insurer shall also be responsible for any damages sustained by the insured due to the delay in obtaining the procedure or test resulting from the insurer's unreasonable denial of such coverage.

(d)                 If the Commissioner determines that an insurer has three (3) or more violations of subsection (a) of this section within a thirty-six (36) month period, such practice shall be an unfair practice pursuant to this chapter.".

SYNOPSIS

This bill requires an insurer who denies coverage for a procedure or test as medically unnecessary to reimburse an insured for all expenses, including out-of-pocket expenses, if the insured pays for the procedure or test and the procedure or test is proven to be medically necessary.

Section 2307 of Title 18 contains the procedures to be used by the Insurance Commissioner when he or she has reason to believe that an insurer has engaged in an unfair practice, such as denying coverage as medically unnecessary.