Connecticut Seal

Substitute House Bill No. 5235

Public Act No. 10-24

AN ACT REQUIRING THE PROVIDING OF CERTAIN INFORMATION UPON CERTAIN DENIALS OF HEALTH INSURANCE COVERAGE.

Be it enacted by the Senate and House of Representatives in General Assembly convened:

Section 1. Section 38a-483b of the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2011):

Except as otherwise provided in this title, each insurer, health care center, hospital and medical service corporation or other entity delivering, issuing for delivery, renewing, [or] amending or continuing any individual health insurance policy in this state, [on or after January 1, 2000,] providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469, shall complete any coverage determination with respect to such policy and notify the insured or the insured's health care provider of its decision not later than forty-five days after a request for such determination is received by the insurer, health care center, hospital and medical service corporation or other entity. In the case of a denial of coverage, such entity shall notify the insured and the insured's health care provider of the reasons for such denial. If the reasons for such denial include that the requested service is not medically necessary or is not a covered benefit under such policy, the entity shall (1) notify the insured that such insured may contact the Office of the Healthcare Advocate if the insured believes the insured has been given erroneous information, and (2) provide to such insured the contact information for said office.

Sec. 2. Section 38a-513a of the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2011):

Except as otherwise provided in this title, each insurer, health care center, hospital and medical service corporation or other entity delivering, issuing for delivery, renewing, [or] amending or continuing any group health insurance policy in this state, [on or after January 1, 2000,] providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469, shall complete any coverage determination with respect to such policy and notify the insured or the insured's health care provider of its decision not later than forty-five days after a request for such determination is received by the insurer, health care center, hospital and medical service corporation or other entity. In the case of a denial of coverage, such entity shall notify the insured and the insured's health care provider of the reasons for such denial. If the reasons for such denial include that the requested service is not medically necessary or is not a covered benefit under such policy, the entity shall (1) notify the insured that such insured may contact the Office of the Healthcare Advocate if the insured believes the insured has been given erroneous information, and (2) provide to such insured the contact information for said office.

Approved May 5, 2010