YOU ARE HERE: LAT HomeCollections


Untangling health insurance troubles

Resolving complaints about unpaid claims and treatment denials can be confusing and frustrating. Here's a guide to getting help.

June 08, 2008|Lisa Girion | Times Staff Writer

Every week, I get at least a dozen queries about health insurance from readers like these:
"Dear Lisa, my husband is scheduled for a colonoscopy . . . . We told the doctor he wants to be put under with anesthesia, and they said our insurance doesn't cover it."
Then there was the man whose fiancee was having "enormous problems" getting bills paid from December, and "every time we call we get the run-around. No supervisor is ever available to speak with us."
It's no wonder my e-mail box runneth over with such pleas. Over the last five years, California regulators logged nearly 100,000 calls and nearly 50,000 formal complaints against health insurers -- HMOs and PPOs alike -- over problems such as unpaid claims, treatment denials and poor attitude.
That might not seem like a lot when you consider that there are more than 20 million Californians with private health insurance. It is perhaps more troubling, though, that complaints have gone up even as the number of insured Californians has declined. Last year there were 12,109 formal complaints, up more than 30% from 2003.
Regulators and law enforcement officials on both coasts have taken note. They have opened several investigations that go beyond sorting out individual problems and are looking into the possibility of systemic illegal practices that result in consumers losing coverage, paying more than they should or not getting the medical care they need. So stay tuned.

Of course, when you can't get your insurer to approve the surgery your physician says your child needs, you want help and you want it now. It is not always easy to solve these problems on your own. If there is one common thread throughout the e-mails I receive, it is frustration -- often to the point of exasperation.

A nationwide J.D. Power & Associates survey last month may help explain why. It found that only 45% of health plan members reported that they fully understood how to use their coverage.

California health plans did not fare well in Power's second annual consumer satisfaction survey. The notable exception was Kaiser Foundation Health Plan Inc., which received top scores from members. Cigna got an "average" rating. The rest -- Blue Shield, PacifiCare, Anthem Blue Cross, Aetna and Health Net -- all received sub-par scores from their members.

Reader e-mails give me a consumer's-eye view of what is driving these sentiments. They present me with endless story ideas and help me sort out which ones seem to be most pressing.

It's impossible for me to respond in detail to each e-mail I get. But when the stakes appear serious, I often pick up the telephone. I do this because it is important for me to understand how the companies and the regulators work. I also jump in because, no matter how pressing my next deadline is, it is hard to turn my back on people in such dire straits.

That's how I felt when Nancy Kolodny's e-mail showed up in my in box. The former Countrywide Financial Corp. executive reached out in a panic after she was dropped from her COBRA health plan and left without coverage for the first time in 30 years.

Kolodny, who suffers from a rare genetic disorder and is dependent upon a $22,000 enzyme treatment every two weeks, was told that her last payment on her health plan was $71 short. She says she never got the notice that the plan administrator claimed to have sent informing her of the $71 premium increase.

Hoping to get her coverage back, Kolodny sent in the difference right away. But it was too late -- a day past the grace period. Sorry, they told her. There was nothing they could do. That's when, in desperation, she e-mailed me.

Please help.

"I've never been delinquent," Kolodny said. "I am a really responsible citizen, and I've never gone without insurance. I've made sure I always had work. I've made sure I always had insurance so I could protect myself and my family."

Kolodny was afraid that she would not be able to get her next enzyme treatment and that her health would deteriorate. So I started making calls.

Her case was complicated. It involved her former employer Countrywide, the Calabasas-based home financing company that is being acquired by Bank of America Corp. in the wake of the mortgage meltdown. It also involved an Orange County firm that administers Countrywide's health benefits for former employees.

I left messages at both companies.

Then I turned my attention to COBRA, the acronym for the Consolidated Omnibus Budget Reconciliation Act of 1986. COBRA is the federal law that requires companies to allow departing employees to continue their health benefits at their own expense for 18 months. (A California law known as Cal-COBRA can extend this coverage for another 18 months, for a total of three years.)

As if healthcare weren't complicated enough, Congress decided to split jurisdiction for COBRA between the Labor Department and the Internal Revenue Service.

I placed calls to both agencies.

Los Angeles Times Articles