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er1Trip and fall breaking your arm at home – no problem.  Slip out of your saddle and break your arm while enjoying your motorcycle hobby – you may get slapped with a major medical bill!

Why?  Health plans do not have to notify individuals and employers of any exclusions or limitations on their health benefits at the point of sale.  Many employers or individual “consumers” shopping for health care coverage are led to believe that care for the broken arm, for example, is the same regardless of how the injury happened – but this is not the case.

But, it looks like help is on the way.  Congressman Michael Burgess, MD (R-Texas), introduced the Burgess Bill (HR1253) requiring more transparency in health insurance.  The bill would make a technical correction to HIPPA (Health Insurance Portability and Accountability Act) and would instruct health plans to notify individuals and employers of any exclusions in health benefits.  The bill recently passed the house and will:

  1. Require that any limitations and restrictions on health plan benefits be explicit and clear;
  2. Require that the health plan be disclosed to the sponsor of the group health plan in advance of sale and,
  3. Require that the issuer, in an easy to understand way, provide participants and beneficiaries a description of the limitations and restrictions as soon as they enroll.

Important to note is the Burgess Bill, originally submitted in September 2008 to the house as HR6908 was received, but no action was taken by the Senate.  Mr. Burgess reintroduced the bill (video HERE) with Congressman Bart Stupak (D-Michigan) as HR1253 (Health Insurance Source of Injury Clarification Act), but it’s identical to HR6908.

Health care transparency is good.  Punishing riders for enjoying their hobby with exceptions buried deep within an insurance plan only to be caught off guard is plain wrong!

UPDATE: April 10, 2009 – Received feedback from experts (thx Kitty!) in the field.  Although the post is accurate, making blanket statements is difficult since each state has different provisions and rules.  However, in the state of Oregon, Individuals (people who are interested in buying their own private policy) are provided with a carrier brochure/application by their broker or the insurance carrier which includes the covered services and exclusions.  With Group Insurance , the employer makes the decision on the plan purchased and is given a copy of the carrier proposal which would include the benefits and exclusions.  All insurance carriers must provide employees with a copy of the employee insurance handbook at time of enrollment.  The book includes covered services and exclusions.  Handbooks are mailed to home addresses by the insurance carrier to be sure employees receive this important information.

Photo courtesy of NBC/ER.

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