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HEALTH PLANS: Does this sound in the least familiar?

From Government News of the Week:.

Connecticut Attorney General Richard Blumenthal (D) said his office has received complaints that Assurant, Inc. denied claims based on questionable conclusions about patients’ pre-existing conditions. The AG’s office said it received 20 complaints against the insurer over the past few years, and that 15 of those claims involved denials for health conditions that allegedly existed before the policies were effective. The claims that were denied came from individual policyholders, Blumenthal’s office said. Also, the Connecticut Insurance Department said it received 111 complaints over the past four years related to Assurant’s denial policies and that only 16 of them were deemed justified by the department. The insurance department started investigating the insurer’s claims-denial practices last year. Assurant Health spokesperson Phillip Chang said the plan is committed to working within all applicable legal and regulatory guidelines of every state it does business in, but could not comment on individual cases.

Of course, it’s unlikely that this type of thing was going on only in California. Meanwhile, long-time THCB readers might be amused to know that Assurant was the company whose HSAs and HDHPs were being pimped continuously on this channel by commenter Ron Grenier. In other words they were among the most underwritten of all policies—and apparently they still had to cancel them after the fact!

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  1. More on Assurant, shame on you!
    Article added: 02/03/2008
    Montanans Owed Money By Fortis On Health Insurance Claims
    FOR IMMEDIATE RELEASE:
    Thursday, September 2, 2004
    CONTACT: Sarah Elliott
    406-444-2495
    31,000 Montanans To Get Letters Asking Them To Resubmit Claims
    (HELENA) State Auditor John Morrison today announced an agreement with
    Fortis Health, now known as Assurant Health, which will result in 31,000
    Montanans receiving letters asking them to resubmit claims that were
    processed incorrectly by the company. A Consent Agreement was reached
    bringing Fortis Insurance Company and John Alden Life Insurance Company into
    compliance with Montana law. The agreement included a $140,000 fine as well as restitution to be paid to certain Montanans. Over 31,000 letters will be
    sent notifying the people affected by the agreement that they may have
    claims that should be reprocessed. Those letters started going out in the mail last week and will continue over the next few months.
    ! SelfEmployedWeb TIP — See our recommendations for Self Employed Health Insurance Options. CLICK HERE
    People who have or had Fortis or John Alden health insurance coverage that
    is affected by this agreement should be receiving a letter in the mail. Claims that are being reviewed are primarily maternity, but persons who were covered by the student medical plan, may also be asked to resubmit claims relating to diabetes, well-child care, inborn errors of metabolism, mammography, post-mastectomy care, reconstructive breast surgery, mental illness, alcoholism, drug addiction and student medical coverage. The agreement only covers claims incurred since January 1, 2002. If you receive a letter you should be aware of the following:
    * Your time to re-submit your claim is limited to 60 days after receiving
    notice, so act quickly.
    * Even if you feel you are lacking critical paperwork, call Fortis Health at
    1-800-800-1212 immediately and ask what you need to do to ensure your claim
    is paid properly.
    * Remember, physicians can often re-print your bills, so don’t be afraid to
    call your doctor if you can’t find all your paperwork.
    * If you have additional questions or problems, do not hesitate to call the
    State Auditor’s Office at 1-800-332-6148.
    “Claims are being reviewed on a case-by-case basis,” said State Auditor John
    Morrison. “It is important that Montanans who have health insurance are getting the full benefits that they are paying for. I am committed to making sure that people who were affected by these issues are properly reimbursed.”
    The investigation of Fortis Health stemmed from a number of complaints to
    the State Auditor’s Office. “Fortis Health has been very willing to correct the problems that were brought to their attention as part of this investigation and worked diligently with the department to resolve these matters,” said Morrison. “We anticipate they will be in full compliance in the future. They play an important role in the health insurance market in Montana. ”
    As part of the settlement Fortis Health has agreed to correct the following
    issues:
    * Failure to send certificates of creditable coverage or sending
    certificates of creditable coverage that did not include the notices
    required by Montana law.
    * Executing a product withdrawal in 2002 without complying with Montana law.
    * Issuing coverage using an unapproved student medical certificate that
    failed to provide certain coverage required under Montana law including
    maternity and diabetes.
    * Failing to consistently provide firm price quotes to small employer
    groups.
    * Failing to provide maternity coverage including coverage for complications
    of maternity.
    Both the State Auditor’s Office and Fortis Health is committed to making
    certain that there is full compliance with the agreement. Follow-up audits
    are planned. If you have any questions regarding claims with Fortis, John
    Alden, or any other insurance, please contact the State Auditor’s Office at
    1-800-332-6148.

  2. Another case of Assurant deception:
    Complaints to Blumenthal’s office involve Assurant Health Insurance’s (a.k.a. Fortis and John Alden Company) retroactive or “look-back” procedures used to bar coverage on the basis that patients’ conditions pre-existed policy onset dates.
    “Compromising coverage of catastrophic illnesses is unconscionable and unacceptable,” Blumenthal said. “The Insurance Department cannot delay this audit any longer — now more than four months old. Its results are vital to coverage for life-saving medical treatment.
    “Improper use of so called preexisting conditions should be barred and banished. My office will continue to fight for stronger legislative protections against these practices.”
    Blumenthal described two of more than a dozen cases under review by his Health Care Advocacy Unit:
    • A 34-year-old woman was diagnosed with Hodgkin’s Lymphoma one month after her enrollment in a six-month policy underwritten by Fortis Health Insurance. During a post-enrollment diagnostic visit, the woman recalled experiencing mild shortness of breath while exercising some six months prior to her doctor’s visit.
    Fortis, in seeking to deny coverage, concluded that the shortness of breath she recalled during a single workout six months prior to enrollment constituted a pre-existing condition because the symptom should have caused her to seek medical treatment prior to enrollment.
    • Another woman is diagnosed with a skin condition weeks prior to insurance enrollment. The patient was covered by a prior Assurant term policy at the time of this diagnosis. Along with the diagnosis and issuance of a topical prescription, the doctor ordered a battery of tests that, subsequent to enrollment, yielded results that prompted him to recommend further assessment. All of these events evolved without undue medical delay.
    Further assessment yielded a diagnosis of cancer, requiring intensive, expensive and life-saving treatment — all covered benefits under the policyholder’s insurance contract.
    In an effort to deny coverage, claiming a pre-existing condition was knowable, Assurant has argued that this patient should have sought medical care before enrollment, even though she did; that the patient received medical advice regarding the condition prior to enrollment, even though her doctor had diagnosed a completely different and distinct condition other than cancer; and that a reasonable doctor should have diagnosed the cancer prior to enrollment.

  3. Health insurance claims settled in Conn. HARTFORD, Conn. (AP) – Three subsidiaries of a Milwaukee-based insurance
    holding company have agreed to restitution and a corrective action plan after
    the state determined that medical claims were wrongfully denied, state Insurance
    Commissioner Susan Cogswell announced Thursday.
    Prompted by consumer complaints, the Insurance Department began
    investigating the companies, which are subsidiaries of Assurant Inc., in
    September 2006. The Insurance Department said it reviewed claims, appeal
    information and underwriting and marketing materials between Jan. 1, 2000, and
    Dec. 31, 2005.
    Cogswell said the agency reviewed more than 500 claims, focusing on claim
    denials for pre-existing conditions, and found that Assurant failed to comply
    with Connecticut’s prompt pay laws, denied claims on the basis of pre-existing
    conditions only to have those determinations overturned on appeal, and delayed
    investigations into denials for pre-existing conditions.
    Rob Guilbert, a spokesman for Assurant Health, would not address the
    allegations by the state but said the insurer is pleased to have signed the
    agreement.
    “We’re always working hard to make sure our claims process is consistent
    with state law,” he said.
    The three companies are Union Security Insurance Co., Time Insurance Co. and
    John Alden Life Insurance Co. The Insurance Department found the use of various
    company names confusing and said the companies should clearly display the name
    of the underwriting insurance company on all forms and communications materials.
    A spokeswoman for the Insurance Department said the agency has not yet
    calculated the amount of restitution to be paid or the number of affected
    policyholders.
    Connecticut Attorney General Richard Blumenthal said that while the
    agreement provides restitution to patients, it does not penalize Assurant.
    “This order is tantamount to telling a thief to return stolen money, but
    imposing no punishment,” Blumenthal said. “This order fails to impose the
    significant penalties warranted for Assurant’s abusive, anti-consumer
    practices.”

  4. Assurant Health overcharged an unspecified number of small businesses between 2002 and 2004 and will have to pay refunds to those clients, state regulators determined in an investigation of the Milwaukee-based insurance company.
    The Wisconsin Office of the Commissioner of Insurance found that Assurant miscalculated rates for small employer customers and must refund each small employer group the amount it was overbilled.
    It’s not yet clear how many of Assurant’s small employer customers, those with between two and 50 employees, had to pay higher health insurance premiums because of the miscalculations, or how far back the miscalculations stretch.
    The insurance commissioner’s investigation of the company — then known as Fortis Health Insurance Co. — pointed out potential overbillings based on a sampling of 2002 and 2003 policies. Fortis changed its name to Assurant Health in 2004.
    The amount that was overbilled will be better known by early June, when Assurant must report a more detailed account of the errors to state regulators, said Susan Ezalarab, director of the insurance commissioner’s Bureau of Market Regulations. Ezalarab declined to estimate how many customers were affected, or how large Assurant’s reimbursement to those clients might be.
    Phone calls to company officials were not returned. In a March 23 statement, the company said it is “committed to complying with all applicable Wisconsin regulations.”
    Millions in premiums
    The company wrote more than $24 million in small group insurance premiums in 2002 in Wisconsin, according to the insurance commissioner. It wrote another $19 million in individual premiums that year, and is considered one of the larger writers nationally of health insurance policies for individuals.
    Questions about overbilling arose during a state investigation of Fortis after an unusually high number of complaints were filed against the insurer in 2002 and 2003.
    Investigators found that Fortis erroneously used occupation as a factor in determining small group insurance rates. State law bars insurers from considering occupation in determining those rates, although factors including age, sex and health of the group can be considered. Excluding certain factors in setting rates helps ensure more common rates and smaller rate swings for small businesses, state regulators said.
    The insurance commissioner occasionally conducts “market examinations” of all insurance companies operating in Wisconsin, Ezalarab said.
    State insurance regulators logged 211 complaints against Fortis between Jan. 1, 2002, and Dec. 31, 2003, according to the report.
    That included 73 complaints about individual accident and health coverage in 2003 alone, or 0.38 complaints per $100,000 of written premium — more than five times the state average of 0.07. It was the highest “complaint ratio” among individual accident and health insurers in the state during that time.
    The majority of the complaints involved “claim handling issues” such as claim denials, according to the investigation. Sixty-seven complaints involved the insurer’s preferred provider organization business.
    The investigation report includes 45 recommendations that Assurant must follow to comply with state law. Many are minor recommendations, ranging from maintaining a more accurate database of agents to revising a brochure it gives to employer customers.
    Violations a concern
    The breadth of state law violations, however, was concerning, Ezalarab said.
    She said there is a general “pattern” of Assurant not following Wisconsin insurance rules, and that the insurer “does not seem to have policies or procedures in place” to do so adequately.
    She said Assurant’s lack of compliance with state-specific rules is especially concerning given that the insurer is based in Wisconsin.
    In the report, regulators ordered Assurant to devise a “compliance plan” and conduct regular audits to make sure state laws are being followed.
    “They need to get a better handle on compliance,” Ezalarab said.
    Ezalarab said Assurant is working to increase the amount of staff dedicated to compliance issues.
    She called the small employer rate miscalculation “a technical issue” and said the company told investigators that it happened following installation of a new rating software system that wrongly built occupation into the formula used to determine small group premiums.
    The company is working to fix the problem, Ezalarab said.
    Insurer taking action
    In a letter to the insurance commissioner dated March 3, an Assurant Health official said the company would not contest the regulators’ report or any of its recommendations.
    Assurant “has begun remedial action for the matters identified in the report that required correction and/or better documentation to demonstrate compliance,” wrote Betsy Pelovitz, director of market conduct for Assurant. “The company is committed to complying with all applicable Wisconsin laws and regulations” and will follow up with a corrective action plan by mid-May, she wrote.
    Pelovitz did not return phone calls seeking additional comment.
    The state will likely continue to track Assurant’s progress in correcting the violations. Fines are possible if the company fails to comply, Ezalarab said.
    Assurant has traditionally been known to charge higher premiums for its small group insurance products, Cyganiak said. Large-scale small employer rate miscalculations are rare, he said.
    Assurant Health is one of four operating divisions of Assurant Inc., which comprises the U.S. insurance operations that European financial conglomerate Fortis Inc. spun off as a publicly traded company in an initial public offering in February 2004. Assurant Health’s headquarters is at 501 W. Michigan St., Milwaukee.
    Wow, can you say Assurant is the biggest rip off? They had the highest complaint ratio in the state for that time frame.

  5. Last week on the job we were handed a few forms to fill out as our company owner was shopping for a new insurance carrier, as Kaiser’s “rates are going up” so we were told.
    The forms wanted extremely detailed information about every aspect of the Medical care I and my family have received since we each saw the light of day.
    This info included a comprehensive list of EVERY medication we had received, EVER.
    It seems to me that such a blatant disregard for privacy so early in our proposed relationship can only come to naught.
    They appear to be already “building their case” for Claims Denial based on “pre-existing conditions”.
    Hope the boss sees it too.
    Best to you.

  6. You folks are amazing. Insurance and people who only take it after they get sick steal from all of us. Many of these cases are accurate. People don’t carry good or any health care, get scared then try and get all of us to foot the bill for their mistakes. You can’t get a car insurer to cover the dents you had before you paid for insurance.
    These folks all whine and cry about the insurance companies but they don’t do what is right until they have a problem and expect everyone to have pity. The other pieces I have read about these cases mention one of these folks had a lump behind her ear and only had it checked out after she got insurance. Who can blame them.
    It is just easy to blame insurance companies so the AG is trying to make politcal headway. Don’t be so simple and listen to him.

  7. I am an insurance agent and tell all of my clients that there are no “good” insurance carriers. Some are just a little less evil than others. My website http://www.flquote.com is well known in Florida for just that reason.
    Given an opportunity, Assurant, et al., will deny a claim. That is why I have my clients list every hang nail they have ever had. By doing so, the application becomes part of the issued policy and serves as an official record. The insured has thrown the ball back into the insurer’s court and it is incumbent upon the carrier to prove that it was a pre-existing condition.
    Guaranteed issue states avoid this problem, but the rates are uniformly high for everyone.
    Let the feds carry excess loss coverage and the insurance companies can lower the rates and handle everything under a certain amount with guaranteed issue plans.

  8. I do… and on a daily basis. You wouldn’t believe the amount of stupid things a group of insurance agents can spew forth when given the opportunity.

  9. The policies of these companies are atrocious. If only you had to deal with the folks selling them….

  10. Ron.
    8^)
    There… see? He didn’t come back afterall.
    Oddly enough, Assurant is pushing some new plans now… something with more “flexibility”… blah blah blah. I still think HSA’s are the way to go, but an HSA is an HSA, and buying a stupid rich plan is still buying a stupid rich plan.

  11. Matt,
    I know you are trying to pay the bills, but do I really have to see UnitedHealth ads when I come to your blog?
    SBD

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