This Week In "Insurance Company Rules"

After the Health Care for America Now [1] coalition unveiled it's brilliant "Insurance Company Rules" video [2] (below) -- elegantly depicting how insurance companies regularly try to make up rules as they go along to deny people coverage and benefits -- I decided to start a new feature: This Week In Insurance Company Rules -- tracking the latest in insurance companies tricks and tactics to keep us unhealthy and uncovered.

This week, we start on a positive note: two stories where government actions denied attempts by insurance companies to lay down "insurance company rules."

The Syracuse Post-Standard reports [3] that a single woman not only successfully challenged her insurance company in an appeal to the New York State insurance department, but her challenge forced the insurer to pay back 2,500 other women as well.

In 2004, an Ithaca woman filed a claim with her health insurance company for a $154 infertility treatment. The insurance company denied her claim, as they did for almost 2,500 other claims for the same treatment.

But the woman from Ithaca was sure the insurance company was wrong to deny her claim. She disputed their findings, but they continued to refuse. So she filed a complaint with the New York State Insurance Department.

Turns out she was right. Last month, the state Insurance Department fined the insurer, and ordered it to reimburse those 2,500 women who had been denied payment.

And in Tampa, the family of a teenage rape victim -- who is in long-term care recovering from a fractured forehead and several strokes from an attempted strangulation -- successfully prevented their insurance company from meddling with her treatment. From the Tampa Tribune: [4]

The victim of a beating and rape three months ago at the Bloomingdale library, who remains in long-term rehabilitation, has gotten some help from the state.

The family of the 18-year-old woman received a letter from its insurance company saying she had to be moved from her current rehabilitation center to another. The family and the teen's doctors disputed the insurer's decision, and the state stepped in.

A Florida Department of Financial Services spokeswoman confirmed Friday that the department's consumer insurance advocate intervened in the case, ensuring that the long-term care will continue uninterrupted.

Jerri Franz, spokeswoman for the department, said the health insurance company that had covered medical costs for the teenager since the attack sent a letter to the family saying the teen would have to be moved to another facility for coverage to continue.

Franz said doctors and therapists disagreed with the plan to move the woman, and the state's advocate intervened.

"Her current doctors felt like it would interfere with her progress," Franz said, "and that she would not be able to overcome that. She would lose ground. So we made a call on family's behalf."

The state cannot force the insurance company to pay expenses, but the unnamed company agreed to allow the teenager to remain where she is, Franz said. "We are extremely pleased that she will be able to stay in her facility."

The Health Care for America Now principles [5] -- which envision a system where private plans have to fairly compete with a public insurance option -- calls for "a watchdog role on all plans, to assure that risk is fairly spread among all health care payers and that insurers do not turn people away, raise rates or drop coverage based on a person’s health history or wrongly delay or deny care."

The above success stories show that government watchdogs are a critical part of the solution to end "insurance company rules" for good.