How to Navigate health Insurance

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Know Your Rights

No small employer or individual employee, regardless of pre-existing conditions, can be turned down by an insurance company for group coverage. This federal law is known as “guaranteed issue.” And every year, the health plan must renew coverage unless there has been fraud or intentional misrepresentation. Premiums may be high, however, and there may be some restrictions if you have a pre-existing condition.

Thanks to the 1996 federal Health Insurance Portability and Accountability Act, insurers can't deny complete coverage as long as you switch from one plan to the next within 63 days and you had been covered for at least a year on your previous job. There may be a 12-month waiting period for any pre-existing condition diagnosed or treated in the preceding six months.

The bottom line: Don’t quit your job and leave a gap in your coverage, especially if you have an existing condition, advises Shearer. If you have been uninsured for several months and then apply for coverage on the individual market, you may be denied or pay a high premium.

Be a squeaky wheel. If you don’t get a referral, are denied coverage, or don’t get an appointment that you think you need, complain to your insurance company. Learn about the plan’s grievance procedure, Shearer says. “You can’t just give up and accept a letter that you are not covered. You need to appeal,” she says.

Consumers have rights under state and federal laws to appeal health-plan decisions they think are wrong. Insurance is regulated by states. If you have problems with your coverage, contact your state insurance commissioner’s office. Also consider complaining to your employer’s benefits manager.

Be an advocate. “Mistakes can get made,” Clancy says. “Insurance companies deal with an astonishing volume of claims. There can be misinterpretations. Many have multiple plans.” If you think something should be covered, speak up. “Your active engagement will make your own health better and will make all of the process better,” Clancy says.