Time is now to make 2020 health insurance selections

Nov. 22--When do you need to select your health care coverage for 2020?

The window for selecting health care coverage is open, but closing soon. Now is the time to review your options for 2020 health insurance and select a plan that best fits your needs. Affordable Care Act ("Obamacare") enrollment opened Nov. 1 and closes Dec. 15. It may be accessed at HealthCare.gov. If, however, you have health insurance through your employer, the deadline may be sooner. Don't delay! Also, on Nov. 1, a new short-term health insurance product became available in Oklahoma. The new policies are less expensive because they are not required to comply with the comprehensive coverage required of ACA policies, such as pre-existing conditions, prescription drugs, and certain other conditions and treatments. They may be purchased any time rather than only during the open enrollment period. Other policies for special circumstances also exist. For instance, if you become disabled, unemployed or change jobs, you may seek coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA), but it is typically quite expensive. Social Security disability benefits can take a long time to obtain. Medicaid can be a good option if your income and condition fits the guidelines. The Oklahoma Healthcare Authority is the State's Medicaid agency. While resources are not limitless, they may increase substantially next year if Oklahoma expands Medicaid.

What legal limitations apply to health insurance and what recourse is available if health care claims are denied?

As you would expect, health insurance is highly regulated at the state and federal levels. The federal McCarran-Ferguson Act reserves regulation of insurance to the states except in certain cases where Congress has passed laws preempting state law. As such, the Oklahoma Insurance Department is the primary regulator and may be contacted with questions or complaints about health insurance, including insurance agents, policies and claims.

What happens when a health care insurance claim is denied?

Because insurance policies are contracts, they contain terms that define coverage and its limits. Policies also include procedures for appealing denials and limitations on coverage. Often the policies contain multiple appeal levels. If an insured is still dissatisfied with a coverage decision, Oklahoma law provides for independent review. After that, an insured may file a lawsuit against the insurance company for payment of claims and, in some cases, other damages if the company acted in "bad faith" in its denial.

What are some of the limitations on a lawsuit against a health insurance company?

As a highly regulated industry, health insurance law can be very complicated. For example, health insurance through most employers is governed by the Employee Retirement Income Security Act (ERISA) -- a federal law that typically limits recovery to the benefits owed. Notably, however, not all employers are governed by ERISA, including health plans "established or maintained for the government's employees." Exceptions include state government plans, although they also have special limitations. This is truly an area of the law in which employers and dissatisfied employees need to seek the assistance of very experienced lawyers in this field.

Kevin D. Gordon is a Crowe & Dunlevy attorney, chairman of the Litigation & Trial Practice Group and member of the firm's Insurance Practice Group.

Paula Burkes, Business writer

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