Insurance grievance law helps several patients

February 22, 2001

Insurance grievance law helps several patients

By LAURA ERNDE / Staff Writer

ANNAPOLIS - A 77-year-old man with a chronic disease who needed a ventilator to breathe was denied insurance coverage for around-the-clock professional caretaker.

But Maryland's two-year-old Appeals and Grievance law changed that.

"This law provides an important remedy for consumers who believe their health plans have acted improperly," said Maryland Insurance Commissioner Steven B. Larsen.

Larsen released a report Thursday on the grievance process, which was the result of legislation sponsored by Del. John P. Donoghue, D-Washington.

Last year, the Maryland Insurance Commissioner investigated 511 complaints from consumers, he said.

Of those, about half were referred to the health education advocacy unit of the Maryland Attorney General's Office because the consumer did not first use the health plan's internal grievance process.

In 120 cases, the carrier reversed the initial denial. In 50 cases, the Maryland Insurance Administration reversed the carrier's denial. In 69 cases, the state upheld the carrier's decision.

Some of the services the insurance commissioner ordered after the health plan denied coverage were:

- A tonsillectomy for an adult to treat obstructive sleep apnea.

- Breast reduction for a 4 foot, 11 inch, 115 pound woman suffering from chronic back, shoulder and neck pain.

- Scar removal for a 19-year-old woman who had been in a car accident.

"It's working exactly how we planned it," Donoghue said.

Because patients and doctors have a place to appeal insurance decisions, HMOs are denying fewer claims, he said.

"They think twice before continuing to drag people along while waiting for an important decision. They can't just wear people down hoping they're going to disappear," he said.

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