Health Insurance Consumers Wield the Power of Appeal

Ronnie Sasser needed a larger "shower table" to bathe her growing teenage son, a quadriplegic who has cerebral palsy, severe mental retardation, cortical blindness and a history of seizures.

The $1,250 table would better stabilize Perry Monroe Sasser while he was being washed, his mother said. She said it was medically necessary because "if Perry Monroe starts to have a seizure on the shower table, at least he's in a controlled environment so you can keep him safe."

Sasser filed a claim with her family's longtime health insurer, Kaiser Permanente. The HMO's mid-Atlantic operation, based in Rockville, rejected the claim, calling the table a "convenience item for the caregiver," not covered by the Sassers' plan.

The rejection letter set in motion a ritual familiar to many Americans: the tedious, at times grueling, back and forth between health insurers and their members over denied claims for prescription drugs, hospital and physician services, and specialized medical equipment.

This week, after the Sassers battled Kaiser for almost two years, the Maryland Insurance Administration took action against the HMO, ordering it to provide the shower table. "Kaiser did not present any evidence to show that a shower table was not medically necessary" for Perry Monroe, the order said.

Most claims sought from health insurers across the nation are processed and paid without a hitch. And insurance commissioners, including Maryland's Alfred W. Redmer Jr., often agree with insurers that they acted appropriately in denying claims. When they side with the patients, regulators usually resolve disputes within a few months.

Redmer has issued more than 100 disciplinary orders during the past two years against Kaiser Permamente, Aetna Inc., Mid Atlantic Medical Services Inc., CareFirst BlueCross BlueShield and other insurers that violated state law by denying claims that should have been paid, a review by The Washington Post has found. Some of the state regulator's orders carried fines of up to $2,500 per offense.

Redmer said the state's five-year-old appeals and grievance law puts health insurers on notice that they are being watched. The law makes Maryland one of the most aggressive states in protecting consumers against wrongly denied claims.

"I am confident that there are a significant number of health care services that are being delivered in 2004 that would have been denied years ago," Redmer said.

Ronnie Sasser said the shower table was one of more than a dozen items Kaiser has denied Perry Monroe in recent years.