Advocacy For Patients files free insurance appeals for consumers with chronic illness

Sep 16 2010

Advocacy for Patients with Chronic Illness, Inc. ("Advocacy for Patients") - one of the only organizations in America that files free insurance appeals for consumers with chronic illness nationwide - today filed comments with the United States Department of Health and Human Services, Department of Labor, and Internal Revenue Service ("the Agencies") both complimenting the Agencies for "the thoughtful approach taken by the Agencies in formulating these complex rules," and suggesting numerous improvements that should be made.

“insurers too often violate consumers' rights by losing appeals, informing consumers that they are not allowed to be represented by counsel, refusing to provide a copy of the claim file, and even simply ignoring appeals that were received but not processed.”

Advocacy for Patients brings a nuts-and-bolts perspective to the regulations, basing its comments on specific cases it has handled, and asking the Agencies to further refine the rules to ensure that unjust results are eliminated by making the process increasingly fair to consumers.

Here are some of the problems Advocacy for Patients has faced repeatedly:

• Insurers fail to provide an address to which to send the appeal. In one case, it took mailing a 350-page appeal three different times to three different addresses in order to succeed in the appeal, thereby delaying care significantly.
• Insurers fail to process appeals. For example, one insurer delayed ruling on an appeal involving treatment for lung cancer for more than five months, repeatedly stating that the appeal was in process when, in fact, it appears to have been lost.
• Insurers fail to acknowledge receipt of appeals, and even to mail appeal decisions. In one case, an insurer claimed to send its denial letter out months ago, but it was not received by either the doctor or the consumer. When the insurer finally sent its denial letter, it was too late to file subsequent appeals, and the State Insurance Department refused to compel the insurer to allow the subsequent appeals.
• Plans base their final decisions on entirely new grounds, depriving the consumer of an opportunity to address new reasoning. In one case, the insurer came up with a new rationale at the eleventh hour and would not allow the consumer to respond despite the fact that she was in the hospital deathly ill at the time and had no other means of treatment.

"Although many insurers are fair and equitable, and take appeals quite seriously," said Advocacy for Patients' Executive Director Jennifer C. Jaff, Esq., "insurers too often violate consumers' rights by losing appeals, informing consumers that they are not allowed to be represented by counsel, refusing to provide a copy of the claim file, and even simply ignoring appeals that were received but not processed." These failures should be addressed by the new regulations.

Specifically, Advocacy for Patients recommended the following:

• Insurers should have to provide an address where appeals should be filed, inform consumers that they can be represented in their appeal, and mail a confirmation of receipt of an appeal to the person filing the appeal.
• If an insurer does not decide an appeal within applicable time limits, the appeal should be deemed granted.
• If a consumer credibly states that he or she did not receive a notice of adverse decision, the time for appealing should be extended until the consumer actually has a notice of the decision.
• When an insurer or outside reviewer bases a denial on new grounds not previously asserted, the consumer should be given an opportunity to respond to that new ground before a final decision is issued.
• There should be some consequences if an insurer does not respond to a request for a copy of the claim file - something to which all consumers have a right.

"It is particularly important for Advocacy for Patients to comment on these regulations," said Jaff, "because we are among very few organizations that file health insurance appeals on behalf of consumers nationwide, so we can compare things that work in some States - like Maryland and Massachusetts' notice provisions - and things that don't in others - like Delaware's refusal to hold Blue Cross responsible for its errors." "Sitting in Washington, it may be difficult to realize how often insurers break the rules because the rules leave room for unfair maneuvers," said Jaff. "We wrote to bring some of the more day-to-day, but significant, concerns to the forefront of the policy debate."

Advocacy for Patients with Chronic Illness, Inc. is a 501(c)(3) nonprofit that provides free information, advice and advocacy services to patients with chronic illnesses nationwide in areas including health and disability appeals, Social Security disability, employment discrimination, family and medical leave, educational equity, and resource location.