HB 216 Summary

• Adds new section 2319 to Title 18, Chapter 23 of Delaware Code establishing standards for insurers denying coverage based on medical necessity determinations.

• Presumes denials of coverage are unreasonable if an insured pays out-of-pocket for a procedure or test after exhausting internal review, arbitration, and external review processes, and the procedure or test is subsequently proven medically necessary.

• Requires insurers found to have unreasonably denied coverage to reimburse insured individuals 100% of all incurred expenses plus any out-of-pocket costs such as deductibles, co-pays, and coinsurance.

• Holds insurers liable for damages sustained by the insured due to delays in obtaining the procedure or test resulting from the unreasonable denial.

• Classifies three or more violations of this provision within a 36-month period as an unfair insurance practice subject to enforcement by the Insurance Commissioner under existing unfair practices procedures.