Friday, November 12, 2010

One wrong denial for contraception coverage leads to company reprocessing nearly 1,000 other claims -- and paying $148,000

One consumer's call to our Insurance Consumer Hotline meant good news for nearly a 1,000 additional insurance consumers. A woman sought our help when coverage for her prescription contraceptive was denied by her insurance company. It turned out that the insurer had been violating a rule Insurance Commissioner Mike Kreidler enacted back in 2001. It had to pay her claim and reprocess 984 claims of other enrollees previously denied, making payments totaling more than $148,000.

From Jan. 1, 2002 to May 25, 2010, the insurer had repeatedly denied payment, under a variety of different codes. Among them: "Condition not covered by this contract", "This service for this condition is not covered by your plan", and "Medical necessity for this service or supply has not been established." The contraceptives in question were IUDs, and the requested coverage was payment for removal of the devices.

Of the 985 claims, only 3 women appealed the decision -- and all the denials were upheld.

But one of those women decided to contact our office. And that led to getting those years' worth of claims, for hundreds of women, paid.

Here's the rule: In Washington, all state regulated health plans that have comprehensive prescription drug coverage must cover prescription contraceptives. Want to know more? Here's a page describing your rights under this state law.

If you've got an insurance question or problem and you live in Washington, don't be afraid to call us for free help. We're at 1-800-562-6900 or AskMike@oic.wa.gov.

Note: Post updated to reflect what kind of contraceptive and service was involved.