RE: Available claims history with "community rated" health insurance policies
Must a health insurance company provide to an insured a detailed claims history including, but not limited to: hospital, major medical, physician and prescription coverages.
An insurance company is under no statutory obligation to provide such detailed information to an insured. However, each health insurance company is required to file with the Department a Quarterly New York Data Requirements form in which certain aggregate claims payment information must be reported. This data is available pursuant to a Freedom of Information Law request to the Department.
A school district is considering various options for health coverage to offer its employees. It is investigating self-insurance and/or joining a consortium. As part of school districts research to evaluate these options, it requested claims information from two health insurance companies that provide insurance coverage to the school district. Both companies responded that since they are community rated products, they do not have claims experience information.
The school district requested this Department to advise it if these companies were required to provide the requested information, and if so, whether there was a deadline within which they had to respond to this inquiry. Specifically, the school district requested of these companies, claims history information including, but not limited to: hospital, major medical, physician and prescription coverages.
There is no provision of the New York Insurance Law which requires a health insurance company to retrieve from its existing data the requested information; nor is there a provision requiring them to keep records in a particular format to enable them to produce the requested data.
Pursuant to N.Y. Ins. Law § 3231 (McKinney 2000) and N.Y. Ins. Law § 4317 (McKinney 2000), health insurance companies are required to provide "community rated" policies providing hospital and/or medical benefits. This means that ". . . the rates set by the insurer must be the same for all people covered by a particular policy form, and must be based only upon its total pool of experience for that policy form. The rates may not be based upon age, sex, health status, or occupation . . ." NEW YORK INSURANCE LAW, vol. 4, chapt. 12.03, 12-19 to 12-22 (Wolcott B. Dunham, Jr. ed. 2001). As a result, it is likely that these companies pool claims expense data by policy form rather than by insureds.
However, each health insurance company is required, pursuant to N.Y. Ins. Law § 308 (McKinney 2000), to file with the Department, Quarterly New York Data Requirements forms that contain data reflecting the amount of claims paid broken down by some of the categories you delineated in your request. However, the data reflects claims paid for all member groups, and is not broken down to reflect payments made on behalf of any one member group. This report may be obtained by filing a Freedom of Information Law request with the Office of General Counsel at the Department.
For further information you may contact Senior Attorney Susan A. Dess at the New York City Office.