The WSJ reported this morning about the health care insurer Assurant (and others) I chose for my company. My employees with "major claims" (anything reguiring surgery, in-patient or out, or potential cancer treatment such as a mole removal, have experienced the scrutiny which comes from a company looking to dump the policy holder. There are endless requests for "more information" from the doctors, the hospitals involved and the patients themselves. They have made repeated identical requests for medical records going back five years, including pharmacy records. Some claims are still pending five months later after all additional information requests have been met. Some employees have been threatened with collection. We have not had an outright denial or recission. Instead we have the stonewall of "pending". Any business considering switching to this company (or any other for that matter) should carefully advise their employees to fully and minutely disclose any reason they ever saw a doctor. Don't omit anything, even something as benign as a sore throat or an ear ache. Also beware of a huge rate increase the first anniversary date. Ours was 40%.
Wall Street Journal, February 27, 2008, Rhonda L. Rundle
Of Nixed Policies
To Counter Negative Publicity,
Industry Pushes Plans to Let
People Appeal Cancellations
By RHONDA L. RUNDLE
February 27, 2008; Page D1
The health-insurance industry is racing to defuse a growing furor over retroactive policy cancellations that have saddled some patients with big medical bills and sparked lawsuits.
America's Health Insurance Plans, an industry group, is pushing a proposal with state regulators that would give consumers the right to appeal such policy cancellations, known as rescissions, to an external panel, whose decisions would be binding. Some insurance companies, eager for even quicker action, are preparing to roll out their own independent review programs.
The efforts, which are getting a largely positive reception from consumer groups, are emerging amid public outrage in several states against insurers that have voided policies after the beneficiaries started racking up large claims for cancer or other serious illnesses.
Last week, an arbitration judge in California awarded $9.4 million, mostly in punitive damages, to a hairdresser whose medical coverage was canceled by Health Net Inc. The insurer, which acted while the woman was undergoing treatment for breast cancer, claimed that she had falsified information about her weight and failed to mention a heart murmur. The judge ruled that Health Net's conduct was "reprehensible" and unlawful.
Such cases have cast an unflattering light on insurers' practices of investigating individuals' medical histories after they get sick. The insurers say they have the right to rescind policies when policyholders don't disclose pre-existing medical conditions that would have disqualified them from coverage, or when they misrepresent information on their policy application. The companies say they are protecting the integrity of the underwriting process and keeping coverage affordable for customers.
But some policy rescissions can seem arbitrary and unfair. Last year, the Connecticut attorney general's office investigated complaints about coverage denials by units of Assurant Inc. In one case, the company refused to pay a 34-year-old woman's bills after she was diagnosed with Hodgkin's lymphoma, according to the attorney general's office. The insurer claimed she had a pre-existing condition because during a postenrollment doctor's visit she recalled experiencing mild shortness of breath while exercising six months earlier, the office said. Under a state order, the company's decision was later reversed and the woman's claims were paid.
"The stories are heart wrenching of people who have paid their money and are relying on the care they paid for, only to have the rug suddenly pulled out from under them," said Betsy Imholz, special projects director at the nonprofit advocacy group Consumers Union.
The controversy about rescissions comes at a time when many Americans are demanding an overhaul of the U.S. health-care system. Indeed, most of the presidential candidates have proposed significant revisions aimed at reducing the ranks of the uninsured. But some critics say that the practice of unfair policy rescissions suggests that private health insurers aren't up to the task of ensuring that sick people maintain coverage.
Companies may void policies after conducting an investigation into patients' medical records, looking for evidence that they were already sick before they bought insurance. Insurance companies say rescissions are unusual, but occur most often when information emerges that a policyholder was pregnant before she bought insurance. Many consumer advocates complain that applications are confusing and that people make honest mistakes in filling them out.
America's Health Insurance Plans, the industry group, hopes its proposal will quell disputes. The group is circulating a draft bill that calls for individual states to use independent panels of health-care professionals and lawyers to review policy rescissions. Details of how the process would function haven't yet been finalized, the group said. Karen Ignagni, the industry group's president and chief executive officer, says the group plans to promote its proposal in a meeting next month with the National Association of Insurance Commissioners, a group of state regulatory officials. "We're operating on a fast track," Ms. Ignagni says.
The proposal for independent review of policy rescissions parallels one that was widely adopted in the late 1990s to resolve fights over health-plan denials for expensive medical treatments. In that appeals process, patients prevail about half of the time.
A spokeswoman for the National Association of Insurance Commissioners said its information about the industry proposal is very preliminary. She said the association first heard of the initiative on Monday when it received an invitation to attend the industry group's presentation.
In California, some big health plans are moving ahead with their own initiatives. In the wake of last week's costly arbitration ruling, Health Net said it won't cancel any more policies until it puts an external review process in place.
Jay Gellert, Health Net's chief executive, said setting up procedures for independent rescission reviews can be done "in a couple or three months." It's not difficult to find lawyers and other people who know how to do this, he said, and "the more objective it is, the better it is for us because it eliminates doubt and provides real clarity." Mr. Gellert said he would support legislation to create a single statewide process, but that could take time and he doesn't want to wait.
Blue Cross of California, a unit of WellPoint Inc., said last week it also is in the process of developing a third-party review process for rescissions. After coming under attack from politicians and others, Blue Cross recently reversed a practice of enlisting doctors to report patients' pre-existing conditions.
A Blue Cross spokeswoman said once a review process is up and running, the company plans to send "every single rescission for review to help us validate the decision."
Consumer groups say independent review could benefit many patients, whose biggest need when a policy is canceled is to get their coverage reinstated, not to file a lawsuit. "We are often viewed as having very different views from the insurance industry, but on this particular matter we think this is a step in the right direction," said Ron Pollack, executive director of Families USA, a Washington nonprofit organization.
A handful of states, including New York and Washington, haven't experienced significant problems with policy rescissions because they have "guaranteed issue" laws that require companies to sell insurance to everyone, regardless of pre-existing conditions. But the industry points to studies that show such states have higher premiums. The industry would ultimately like to see guaranteed issue married to laws that require everyone to purchase insurance, creating a larger financial pot for claims payouts.
Write to Rhonda L. Rundle at email@example.com