misrepresented a health fact that materially affected the insurer's
decision to grant coverage.
-- Even if a third party panel includes laypersons and legal experts, it is
not good policy to have a company -- whether for-profit or nonprofit --
with financial interest in retaining its contract with the state replace
a judge and jury.
-- The "facts" of a rescission review -- whether a patient lied
-- require an exhaustive review of the rescinded patient's actions,
unlike existing third-party medical reviews that consider the
particulars of a diagnosed medical condition and do not require an
interaction with the patient. The two situations cannot be compared.
-- The existing third-party independent medical review has come under
increased scrutiny and criticism for failing to observe the appropriate
statutory requirements when conducting reviews, and the Department has
been lax in its oversight.
-- Insurers may at any time bring pressure to bear on the regulators and
seek termination of a contract if a reviewer too often returns
unfavorable results. In fact, the IMR review process under a company
known as Maximus sides with health plans in 70% of the cases it reviews.
That's why the insurance companies have publicly supported the same
system for rescission.
-- The great majority of rescissions involve the actions of insurance
brokers who often counsel patients about how to fill out the complex
applications of the individual insurance -- recommendations that are
often colored by the insurance agent's financial incentives in
selling coverage. Who would review the agent's action in the
third-party review? Who would judge the weight of that evidence?
|SOURCE Consumer Watchdog|
Copyright©2008 PR Newswire.
All rights reserved