Health Insurance Consumers Wield the Power of Appeal

Many of the Sassers' claims, including one for a wheelchair, were paid only after the Maryland Insurance Administration took disciplinary action against Kaiser. In November, the state regulatory agency ordered Kaiser to pay for the shower table. The HMO appealed the order.

"I have been put through the gates of hell and back by Kaiser," Ronnie Sasser wrote in an e-mail to The Post.

Kaiser spokeswoman Amy Goodwin said in an e-mail that since 2000 the HMO has paid more than $440,000 in claims for Perry Monroe Sasser's medical care. Denied claims have totaled less than $14,000, she wrote. These claims were denied because the services or supplies were medically unnecessary or were not covered by the Sassers' plan, she wrote.

Kaiser declined to elaborate even though Ronnie Sasser signed a waiver giving the HMO permission to fully discuss her 15-year-old son's case with a Post reporter.

Unlike most HMOs, Kaiser Permanente acts both as an insurer and health care provider: It has 29 medical centers that employ about 900 doctors in the Washington-Baltimore region.

"The care Perry Sasser has received as a Kaiser Permanente member since birth reflects our commitment to both Perry and the Sasser family," Goodwin wrote.

Health insurers argue that claims must be denied at times because patients seek reimbursements for drugs, services and equipment that are not medically necessary or covered under the policies they bought. If these claims were paid, premiums would have to be raised, they say.

Denied claims, said Philip S. Carney Jr., the top medical official in Kaiser's mid-Atlantic operation, make health care affordable for those who follow coverage rules.

Often, though, insurers must grapple with "gray areas" in deciding what is -- and isn't -- medically necessary, Carney added. And often it's left to insurance commissioners to turn the gray into black and white.

"Typically, the problems revolve around poor communication" between insurers and their members, Redmer said. "But there are also genuine disagreements" over medical necessity.