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VOICE Speaks Out Over Insurance Abuse : Consumers: It's not just the denial of coverage that has people calling for change. They say health insurers have too much control over their lives.

June 01, 1993|SHARI ROAN | TIMES HEALTH WRITER

Like any loving, dutiful daughter, Marian Miller was prepared to oversee the care of her elderly parents when they became ill a few years ago. But the Redondo Beach woman didn't anticipate having to take on the insurance industry on their behalf.

Miller, 43, not only waged war against an insurance company that denied her parents' medical claims, she founded a nonprofit organization to encourage consumers to fight back when they feel they've been wronged.

Victims of Insurance Company Errors (VOICE) is one of the few organizations seeking to educate and advise consumers on health insurance matters. (The group also has a lobbying arm in Washington.) As health-care costs rise and insurance restrictions tighten, Miller says, there is more need than ever for consumers to be wise and wary.

That's what she learned when her parents' insurer began to deny what the family believed were valid claims.

"This is not just about denying insurance coverage," says Miller, a pleasant, soft-spoken mother of two young children. "This is about crushing the human spirit. We have to deal with health problems--that's something we can't control. But it's having to deal with this other force--the insurer--also controlling you that's so hard. My mother lost her will to live because of it."

After years of ailing health, Miller's parents needed care in a nursing home. Miller, her parents and the family doctor reviewed the couple's insurance policy and agreed it would cover such costs.

But their claims were repeatedly denied. The couple had to rely on their savings to pay for their medical care while Miller fought the insurance company. Her mother died during the battle.

"I was infuriated," Miller says. "My parents would say things like, 'Let's just hope we die before our money runs out.' I knew their claims were valid."

The money did run out, and Miller's father went on Medicare before Miller filed a lawsuit and settled with the insurer.

But she couldn't let the matter rest. Miller went on to investigate insurance problems encountered by the elderly, and became convinced that consumers need to unite to argue for their rights.

Most people won't fight back when they encounter problems with their insurers, she says, and "insurers know that only the most tenacious people will get their claims paid."

Just how often consumers are wrongfully denied insurance reimbursement is hotly debated. The majority of claims are handled professionally and correctly despite numerous obstacles, says Fred Hunt, president of the Society of Professional Benefit Administrators, a trade organization for self-funded employer insurance plans.

"I'm astounded at how good the service is, frankly," Hunt says.

He says shoddy claims, incomplete information and missing records often trip up consumers seeking reimbursement. Moreover, many consumers don't understand what their policy covers.

And, Hunt adds, many consumers, with the aid of their doctors, file claims with false diagnoses to hide a diagnosis that wouldn't be covered.

The biggest problem, though, is that people don't know what is covered, he says: "We tend to apply wishful thinking to what we want covered."

But some consumers tell a different story. Their complaints about insurance companies range from claims of unfair treatment to cases of outright fraud.

Kathleen and Bill Harvey of San Diego had paid into a university alumni group insurance plan for four years before trouble began.

Their oldest daughter, Marissa, required surgery at age 3 because her only kidney was partially blocked. Marissa's health outlook was good, although the Harveys were told that she should be examined three or four times a year to make sure the kidney functioned properly.

Three months after the surgery, the couple's insurance premium doubled. Within three years, it doubled several times again--to $16,000 a year.

"I didn't know much about consumer rights, but I knew I had to do something," says Kathleen Harvey. "At first, as a victim, you feel sorry for yourself. But then you get angry. The insurance industry has so much money to spend to get attention. I'm worried that there are not enough consumer voices being heard."

She wrote letters to elected representatives, joined Miller's organization and ended up testifying in Washington last year about unfair insurance practices.

But their problems were not resolved. The Harveys eventually had to drop all but one of their children from insurance coverage, and Kathleen has gone back to school, hoping to land a better job--with health benefits.

Still, she says: "People shouldn't have to change their jobs the way I've had to."

The Harvey family is not alone. Federal authorities report that complaints about health insurance coverage have soared in recent years.

And one of the biggest barriers to consumer rights, activists say, is that a long-standing federal law has allowed self-funded employer insurance plans to operate without regulatory oversight and without penalty when consumers' rights are abused.

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