PA 10-24—sHB 5235

Insurance and Real Estate Committee


SUMMARY: This act requires certain health insurers who deny coverage of a requested service because it is not (1) medically necessary or (2) a covered benefit to notify the insured of his or her ability to contact the Office of the Healthcare Advocate if the insured believes he or she has been given erroneous information. Insurers must also provide the insured with contact information for the healthcare advocate's office.

The act applies to each insurer, health care center, hospital or medical service corporation, or other entity that delivers, issues, renews, amends, or continues in Connecticut individual or group health insurance policies that cover (1) basic hospital expenses; (2) basic medical-surgical expenses; (3) major medical expenses; or (4) hospital or medical services, including coverage under an HMO plan.

Due to federal law (ERISA), state insurance benefit mandates do not apply to self-insured benefit plans.

The act also imposes a 45-day coverage determination and notice requirement on any of the above entities that continue an individual or group health insurance policy in Connecticut. The law already requires this for individual and group policies that are delivered, issued, amended, or renewed in the state.

EFFECTIVE DATE: January 1, 2011


Medically Necessary

The law requires policies to include the following definition of “medically necessary. ” Medically necessary services are health care services that a physician, exercising prudent clinical judgment, would provide to a patient to prevent, evaluate, diagnose, or treat an illness, injury, disease, or its symptoms, and that are:

1. in accordance with generally accepted standards of medical practice;

2. clinically appropriate, in terms of type, frequency, extent, site, and duration and considered effective for the patient's illness, injury, or disease;

3. not primarily for the convenience of the patient, physician, or other health care provider; and

4. not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results.

“Generally accepted standards of medical practice” means standards that are (1) based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community or (2) otherwise consistent with the standards set forth in policy issues involving clinical judgment (CGS 38a-482a and 38a-513c).

OLR Tracking: ND: VR: PF: ts