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Health & Medicine

Consumers Continue Receiving Wrongful Insurance Denials

— December 1, 2023

Despite lawmaker pushback, insurers are still denying a large number of claims.

In a startling revelation, it has come to light that health insurers have consistently flouted state laws enacted over the last four decades to protect consumers from wrongful insurance denials. While states have passed numerous laws mandating specific coverage to prevent financial burden and medical neglect, insurers have repeatedly violated these mandates, leaving patients without vital medicines and procedures.

Despite legislative interventions in various states, from North Carolina to Arizona, the violations persist. In North Carolina, a measure was enacted to ensure breast cancer patients’ access to reconstructive surgeries, while Arizona focused on protecting diabetes patients by mandating coverage for necessary supplies. These efforts, echoed by lawmakers across the nation, have been undermined by insurers disregarding the state-imposed obligations.

ProPublica’s investigative report delves into the egregious cases where patients were denied coverage for life-saving treatments. The investigation spotlighted a Michigan company that refused to cover an FDA-approved cancer medication for Forrest VanPatten, violating a state law requiring coverage for cancer drugs.

Tragically, VanPatten, denied his only chance for survival, passed away at 50 while still battling the insurer for access to the therapy.

Consumers Continue Receiving Wrongful Insurance Denials
Photo by Kindel Media from Pexels

While state insurance departments are tasked with enforcing these laws, they face significant challenges. Many are understaffed and prioritize the financial stability of insurance plans over protecting consumers from wrongful denials.

Researchers and consumer advocates argue that these agencies lack the resources for comprehensive audits, leaving enforcement dependent on individual complaints. Regrettably, this means denials often go uninvestigated unless policyholders or their families actively pursue complaints.

ProPublica’s investigation identified a mere 45 enforcement actions since 2018 related to denials violating coverage mandates. State insurance departments frequently treat consumer complaints as isolated incidents, addressing individual cases without probing broader systemic issues.

However, when regulators have delved deeper, they have unearthed instances where a single complaint unveils a pattern of wrongful denials affecting thousands. As a result, one of the most significant challenges faced by consumers is a lack of awareness about their entitlements under state mandates.

A survey revealed that 86% of people with health insurance are unaware of the government agency to contact for assistance. This knowledge gap leaves patients vulnerable to unwarranted denials, contributing to the rising issue of exorbitant medical bills.

Legislators in some states also face ongoing battles to compel insurers to comply with coverage mandates. California, for instance, had to enact two laws to ensure coverage for infertility treatments, and lawmakers are considering a third due to persistent denials.

State Sen. Anthony Portantino worked to amend the law in 2019, stating that these treatments must be covered. There are too many couples spending thousands of dollars simply hoping to start or expand their families. Coverage is even lacking for those who received other treatments (including cancer interventions) that left them infertile.

“Some of the insurers are taking a very strict approach that it has to be chemo,” said Portantino (Democrat).

The toll on patients who face wrongful denials, sometimes with life-threatening consequences, demands a comprehensive and proactive approach to ensure that state laws intended to protect consumers are not merely on paper but are enforced to safeguard the health and well-being of millions.


Health Insurers Have Been Breaking State Laws for Years

KFF Survey of Consumer Experiences with Health Insurance

Health insurers have been breaking state laws for years

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