Every law depends on enforcement. Once a law is passed, it has to be backed up by the courts, but the courts have to have something to work with in the first place. These are all good provisions. Prohibiting denial of coverage for preexisting conditions, for example, should also deter insurance companies from falsely claiming a condition pre-existent when it was not, as with a woman who wrote to me about her daughter, a college student who contracted meningitis. Her university ˜health plan' carrier tried to assert that the meningitis was a preexisting condition. The company lost that one, fortunately.
The work is by no means done. But people who dismiss this legislation are being careless at best. The very fact that the U.S. Senate has enunciated a principle, to be implemented through law, that employees cannot be excluded from a group health plan based on their salary is monumental. Limiting to $5,000 the amount a covered individual can be forced to pay for medical bills is also a huge saving grace.
Now going back to the other part of your question, we do know some things about the extent of the problem. Even if we do not know the total dollar value of claims denied, for example, we do know the names of companies that have been taken to court and/or examined by regulating authorities, generally settling when they're caught.
A few of the significant examples:
- UnumProvident, the leading provider of group disability insurance in the U.S., and its subsidiaries Colonial Life, Provident Life, and Paul Revere allegedly systematically denied claims for which policyholders should have been covered. The company settled.
- The number of denied claims by Cigna, Guardian/Berkshire, MetLife, and NY Life, leading providers of group disability insurance, has risen in the last few years.
In Connecticut, regulators re-examined hundreds of insurance claims denied by Assurant Health. According to the Connecticut Insurance Department, over 800 claims were denied by Assurant companies from 2001 to 2007 by alleging that patients had health problems that pre-dated their policies.
The Los Angeles Times reported that the California Department of Managed Health Care concluded that Blue Cross of California improperly canceled individual health insurance policies after some members became pregnant or sought medical treatment for chronic conditions. Blue Cross in California settled.
California Insurance Commissioner Steve Poizner announced a settlement with United Healthcare over claims payment practices. The multi-state settlement, according to the statement for public release, "involved 37 states working together to protect consumers.
- Looking at figures from some state insurance commissioners, in New York there were 2,959 complaints against health insurers in 2006, 745 upheld on external review by the NY State Dept. of Insurance; also 11,280 internal appeals with 4,649 reversed (524 and 197, respectively, for WellPoint).
- From the Texas Dept of Insurance 2006 Accident and Health Complaint Index, a total 1,684 justified complaints. Companies against which numerous complaints were filed included Aetna, BCBS, Humana, UniCare, and United HealthCare.
Of thousands of complaints about health policies in the five largest insurance markets "California, New York, Texas, Florida and Illinois--the overwhelming majority involved bad or questionable claims handling. Common sense tells you that a few days' delay in every claim, multiplied by thousands of claims, adds up to billions for the companies. (Often, people do not know their state commissions or know how to file a complaint.)
By the way, critics of Medicare often omit to mention that one of Medicare's big problems is private insurers. On Oct. 7, 2007, the New York Times reported that 91 federal audits showed tens of thousands of Medicare recipients systematically had their claims improperly denied by private insurers. Audits revealed improper terminations of people with HIV/AIDS; huge backlogs of unprocessed claims and complaints; and failure to answer phone calls from consumers, physicians and pharmacists. Companies audited included UnitedHealth, which services six million Medicare recipients; Humana, with more than 4.5 million; and WellPoint, which owns Blue Cross of California. Problems included UnitedHealth's improperly denying claims without explanation to beneficiaries; Humana's not explaining claim denials or not informing beneficiaries that they could appeal; and a backlog of 354,000 claims in WellPoint subsidiary UniCare.
A report by the House Oversight and Government Reform Committee showed problems in Medicare drug coverage by private insurers.
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