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CA Legislature's 'Reform' of Health Insurance Cancellations Resembles Insurance Industry's Own Plan; Insurers, Satisfied With Getting a Legal Edge Against Patients, Drop Opposition to the Bill

For a rescission to be rightful, an insurer must prove a patient

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-- require an exhaustive review of the rescinded patient's actions,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

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