My brother, John, who is self-employed, 58, single and lives in California was on a several month long RV camping trip hundreds of miles away from his home when he was diagnosed with bladder cancer this past February. All of his family (parents, siblings) are on the east coast and we urged him to come east so that we could provide support and care for him through the required treatment.
Pondering that possibility, he called his health insurance company, Healthnet (CA) to determine what the consequences of obtaining treatment in Pennsylvania would be. He was told that the only difference in coverage would be that instead of having an annual $3,500 deductible requirement and co-pays, his deductible for out-of-network treatment would be $5,000. He thought being near family was worth the extra $1,500 OOP and we (his family) agreed.
He has been a Healthnet subscriber paying premiums to them for about 10 years and in that time never had a claim that exceeded his deductible.
Consequently, based on his numerous inquiries to Healthnet, John did come to PA, had consultations with doctors from UPMC (U of Pitt Medical Center); two surgeries, six BCG chemotherapy treatments over the course of 5 months. UPMC was also in contact with Healthnet, verified to their satisfaction, based on the information that Healthnet of CA gave them that John was covered for the procedures and care they were about to provide. UPMC proceeded to collect the necessary co-pays for each admission to the hospital and the office visits, etc...
Once the bills began to come in, Healthnet denied the claims stating that John's treatment for this obviously covered condition was only $1,000 day for inpatient care and there were only two inpatient hospital days. John has received bills for over $65,000 so far and more are coming. John appealed the denial. He received the final denials (from Healthnet) of his claims this week. He has appealed to the insurance commission in CA. UPMC has begun collection efforts even though they agree that Healthnet gave both John and them assurances he was covered.
Buried in the 70 page insurance policy....some 23 pages after the statement that out-of-network care requires a larger maximum annual OOP, is a small clause stating that out-of-network treatment coverage is limited to $1,000/day for in-patient care. Due to the fact that surgery for bladder cancer is scheduled as an out-patient procedure and John required only one day beyond the out-patient
Surgery day, Healthnet has paid only $750 on one claim so far.
Faced with the denials, John returned to CA, and recently learned that the chemo treatment was not successful. He has to have his bladder removed. He is receiving treatment in-network now and will have the surgery to remove his bladder and make a new one on October 11th. Healthnet is covering this additional treatment.
My question is this: Is this not a case of bad faith on the part of Healthnet? How could anyone diagnosed with cancer while hundreds of miles from home, without the 70 page copy of their health insurance policy in hand determine their coverage other than calling their insurance company? How could he have possibly known that what the Healthnet representatives told him and UPMC was untrue? Could it be that Healthnet deliberately gives their customers erroneous assurances of coverage to mislead them so that Healthnet can deny coverage in what they would otherwise have to pay?
John has requested the recordings of his conversations with Healthnet and has received nothing. He suspects they have been destroyed or are being withheld because they prove that what he is saying is correct.
I know that Healthnet lost a huge lawsuit recently due to rescinding policies unfairly. This situation seems at least as egregious. John's treatment would absolutely be covered had he been in network. And there would have been no $1,000/day limit. Ironically, the care received in PA was less expensive than the same care John would have recieved in CA.
Are any agents here familiar with Healthnet of CA and/or have experience with similar cases (and willing to share it)? Any advice of how to proceed? John is sick, weakened by his condition and now emotionally battered by this experience with Healthnet. He is currently pretty well beaten down to a nub. I know that he doesn't have the strength at this point to institute a lawsuit....but I sure think that he has grounds for one. How can the people running that company sleep at night?
Last edited by pipedream : 09-22-2009 at 02:52 AM.
Reason: change to correct age of brother....he's not 59 until next month!
I'm from Health Net ... I'm happy to take a deeper look into this to see if there's anything we can do ... please send me an email at brad.kieffer@healthnet.com with your contact info.
Most of the folks you talk to in customer no service at the carriers don't have a clue what they are talking about. It is up to the policyholder to read and understand what they have and don't have with regard to coverage.
Out of network penalties can be quite severe (as you have noted). In addition, you are dealing with non-par providers who are not bound by negotiated rates and can charge anything they wish.
All that said, hopefully the guy from HN who responded will be able to assist.
I would recommend that you gather every shred of paper you have... each bill, each letter (as well as form letters) and make a copy and put them in chronological order... oldest first.
Write a narrative or summary about the issue, similar to what you did here but in far more detail... with dates, names, places, etc. Perhaps write is like a press-release.
With a post-it note annotate anything important and stick it on the paper you got from HN (they make very small post-its.) Don't write on the documents or bills themselves.
Get a scanner (or go to Kinkos) and scan all of this stuff to one big PDF file and burn it to CDs for safe keeping and distribution.
Get yourself 2 presentation binders (or photo binder) that allows you to slip all the paper you scanned into plastic sheets. Keep one to show, give the other binder (and CD) to someone you trust and don't ever tell who... no one. (Would a carrier hire some "nice guys" to break into your home and try to obtain all the "evidence." Does a duck quack?)
Find a lawyer who has sued HN or an health ins. company before (link above might help.) If local, show the binder. If not, send them the CD. Ask if they will take case on contingency.
If you can't find a lawyer, take the binder or send the CD or PDF to several large newspapers and TV stations that do investigative reporting. Start local first and build out if you can't find anyone interested in the story. (You can always call the editor or producer and ask whom to send your story to.)
If what you say is true and you can support it, not only will you be on 60 Minutes in a few weeks, you might get an invitation to testify before Congress... or maybe appear with the President.
I noticed that a representative from HN is on the board and offered to review the case. That's fine. But you need to do all the above anyway and find a lawyer (law firm) that has experience in this. Otherwise, go to the media.
Oh, and try to get power of attorney from your brother if you have not already done so.
Keep us informed. I think most agents on this board will (always) side with the carrier because... that's their bread and butter. Most here don't see "people" they see "dollars." I'm not one of them and there are a few others here like me as well. If you need advice feel free to contact me.
Once John was aware there was going to be a problem he documented every conversation with Healthnet and has retained all paperwork. And he went back through phone records to determine dates and times he talked with Healthnet starting with his diagnosis in February. He has compiled a very good chronology which was submitted in his complaint to the insurance commission. He continues to document everything.
It just blows my mind that this has happened. There is no one more careful about making sure he understands "the fine print" than my brother John. There is no way he misunderstood what he was told. I had numerous contemporaneous conversations with him when he was making the decision to come to PA for treatment. John sought reassurance from Healthnet on more than one occasion and it was clear that the only repercussion to going out of network was the additional $1,500 deductible.
Cleveland Clinic is only about an hour further than UPMC from his home base in PA and it is in Healthnet's network....He could have gone there had he been accurately informed of the consequences of going out of network.
Does anyone really believe UPMC would have provided the services they did if Healthnet told them John would not be covered? The billing people at UPMC are professionals who do this all day every day. It's their job to determine coverage. If they couldn't accurately determine coverage in their numerous contacts with Healthnet, how is a sick subscriber far from home supposed to do so?
I also plan to contact hn_bradkieffer
Thanks again for taking the time to respond to my post and for your assistance. I'll keep you informed as to status.
I would contact Brad before doing any serious work or spending a lot of time compiling the info. A quick google search shows that Brad clearly has the authority and contacts in the company to see that there is a smooth resolution.
I recommend contacting him, and giving specific requests for what a resolution would look like, along with a specific timeline.
Lawyers can often be very helpful, but they can occasionally be very unhelpful to your cause, and should be used when you exhaust other options.
No, I don't know Brad, but I was impressed with how quickly he responded with an offer to help.
Oh, great...sounds like Health Insurance companies have provided themselves with a bullet proof defense by hiring "no-nothing hourly employees" to answer questions from subscribers and providers. They count on subscribers naively believing they can call the company and get answers they can act upon with confidence. (Yuk,yuk...what a schmuck...)
So when posing the question, i.e., "Hi, I'm hundreds of miles from home and I have just been diagnosed with cancer. I don't have a copy of my policy with me, please help me determine my options for treatment,etc...." - a person should just know intuitively that what the employee of the health insurance company says is completely untrustworthy and to be disregarded?
The problem is that no one knows these things until it is too late. A generally healthy person paying premiums year after year is unaware that there lies within his policy a complex, labryinthian maze complete with loopholes buried in the fine print 23 pages from the main benefits page which would be difficult to navigate under ideal circumstances. And impossible to navigate when in shock due to a devastating diagnosis and in horrible, debilitating pain from what my brother has described as "unspeakable medical procedures". (It took a very long time after the policy was requested to receive a copy so even if he wanted to read the policy in full, it was impossible to do so for several months.)
On a more positive note, I heard back from Brad Keiffer after emailing him. I provided identifying information so he can look into my brother's situation.
I also learned today that the collection agency has agreed to take weekly payments of $200 for six months before taking more drastic measures to collect the medical bills that Health Net is refusing to pay. That gives John a little breathing room before he has to worry about losing his home. He can go into surgery Oct 11th to have his bladder removed and reconstructed knowing he will have a home to return to...if only temporarily.
While I was composing my last post and after I hit "submit", I received the following email from my brother. The information in it puts a clearer light on the situation than I was able to.
Here is what he wrote: "I was away from home, hundreds of miles. I did not have access to my files, and had no other way to get information except from Health Net. I spent 38 minutes on the phone with Health Net, with the main topic being "coverage at UPMC.
I believe that there is a pattern of misinformation. Getting information from HN is like pulling teeth, and I now have several well documented examples of misinformation being offered. Insurance companies are not permitted to "Misrepresent to claimants pertinent facts or insurance policy provisions relating to any coverages at issue" Ca. Insurance Code section 790.03(h). Words have meaning, and they should be required to give accurate information. Detrimental reliance..... at the least.
If their representative is unable to provide correct information, then these issues should be referred to a supervisor. A newly diagnosed cancer victim should not be expected to know that he is likely to get incorrect information from the insurance co, nor be expected to ask carefully crafted questions regarding coverage issues. The information that I sought, is straight forward, and could have been provided quickly and accuratly.
UPMC lowered the cost of the procedure to what Health Net said that it should be.... just as if they were contracted with HN."
If he has an agent he needs to put that agent to work to fix this for him. Agents can get a lot done behind the scenes working with the carrier. He really should have worked through his agent before he had this done.
If he bought direct from the carrier and has no agent, then you can now see the disadvantage to saving no money doing that and cutting out a real resource.
Agents can get a lot done behind the scenes working with the carrier. He really should have worked through his agent before he had this done.
You spoke volumes in those few words. Some days it seems I spend time trying to correct things clients did after the fact. It would have been much easier (for all of us) if they had asked in advance.
I wrote to John last night: "An agent on the forum is asking if you contacted and talked with your agent about this? Please let me know so I can respond."
I received this answer this morning: "Good morning, No, I bought this policy about 10 years ago, and really never talked to the agent again."
Now before anyone berates my brother for never talking to his agent again after purchasing the policy (remember he was healthy and did not have expenses beyond his deductible in the 10 years he has owned the policy) I have a question for you. Do agents have any responsibility to keep in touch with their long-term customers who seemingly don't have issues...who just keep paying the premiums year after year? And do you suggest he try to locate his agent now for assistance?
Some agents are more hands-on than others, however in a situation like your brother's if he was happy with the plan and not having issues, then it is not incumbent on the agent to continually contact him.
That being said, the agent does earn continuous commission on the plan over the years and that commission is intended to provide service on the policy. The agent should be ready at any time to assist a client with claims issues if and when they arise.
Hopefully your brother's agent is still in business. Should he/she not be, it is then possible that servicing come directly from the carrier.
I believe on his premium payment statements it should list the name of his agent.
Hopefully your brother's agent is still in business. Should he/she not be, it is then possible that servicing come directly from the carrier.
Follow-up from John as to the agent: The agent that I bought from is no longer with the agency. Another agent has apparently taken over my file. I was in the process of trying to get out of the expensive "sick" pool when I was diagnosed. I don't have any other insurance with that agent, as I was living in Anza when I first got the policy. When I told my agent that I had cancer, she said "good luck", and I haven't heard from her since..... "
Healthnet of CA - Advice Needed
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