Health Insurance Consumers Wield the Power of Appeal

Under Maryland law, patients must first appeal denied claims to their insurers. If the denial is upheld by the insurer, a patient can file a complaint with the Maryland Insurance Administration, which hires independent reviewers -- usually doctors with specialized training in the areas of dispute -- to investigate. Decisions ultimately are made by the regulator with help from the state attorney general's office. Insurers can appeal decisions.

Patients who can establish with the regulator that they have pressing medical needs can appeal directly to the insurance administration without filing an appeal to their insurer.

It's clear that patients often can get their way if they appeal denied claims to insurers, then, if necessary, to state regulators.

A recent study of two large health insurance plans in California reported that 90 percent of all denied claims for hospital emergency room visits were paid after patients filed appeals. The study by the Rand Corp. and Harvard School of Public Health said the average cost of the denied ER visits it examined was $1,107.

In Maryland, just over half of the denied claims the regulator investigated in fiscal 2003 -- from July 1, 2002, through June 30, 2003 -- eventually were paid, according to preliminary data obtained by The Post. (The agency will release fiscal 2004 data later this year.)

In 69 cases, the insurance administration reversed -- fully or partially -- insurers' decisions to deny claims. In 74 more cases, insurers reversed their own denials -- agreeing to pay the claims -- after the regulator opened an investigation.

In 137 cases, the agency agreed with insurers that claims should not be paid.

Insurers deny claims for a wide range of reasons, a review of disciplinary orders found. Copies of the orders were obtained under Maryland's Public Information Act.

On June 27, 2003, for example, Aetna denied coverage of a weight-loss procedure to a 30-year-old, 6-foot, 300-pound man who had diabetes, hypertension, coronary artery disease and other conditions.

The patient appealed the denial to Aetna. On Sept. 10, 2003, Aetna upheld its decision, saying the patient had not documented a five-year history of morbid obesity -- a requirement for paying the claim, the insurer said.

After the patient filed a complaint with Redmer's office, the case was reviewed by a surgeon with a subspecialty in gastric surgery. The reviewer concluded the patient had various "life-threatening" conditions and was "at extremely high risk of death within ten years."

Redmer ordered Aetna to pay for the surgery.

Also last summer, Mid Atlantic Medical Services refused to pay for a three-night hospital stay for a 36-year-old woman who had metastatic breast cancer. She was admitted to Gettysburg Hospital in Pennsylvania with severe back and leg pain. In denying coverage, Mid Atlantic Medical said her condition didn't require treatment at an acute care facility such as Gettysburg.

The woman appealed to the insurer and the claim was again denied. A state reviewer concluded that the hospitalization was appropriate for a cancer patient who needed "aggressive treatment," the reviewer wrote. The patient has since died.

The Sassers' claim for a larger shower table was first made in 2002. After Kaiser denied the claim in January 2003 and upheld its denial on appeal, Sasser filed a complaint with the insurance administration.

The state reviewer, a pediatrician with a subspecialty in neuro-developmental disabilities, concluded that the shower table should be provided. "A child with this degree of involvement needs a safe system for personal hygiene maintenance, particularly as increased size and weight preclude lifting into and out of a tub," the reviewer wrote.

On Nov. 25, the agency ordered Kaiser to provide the table. Kaiser requested a hearing to contest the order. On May 4, Ronnie Sasser and Kaiser officials met at the insurance administration offices in Baltimore. Kaiser's appeal was denied on Monday.