FOUL PLAY

Insurance company mistreatment


  • "After an unprecedented eight-month joint state probe triggered by hundreds of complaints, state health insurance regulators Tuesday slapped the PacifiCare unit of UnitedHealthcare with a record $3.5 million fine. Regulators also will ask an administrative law judge to uphold its allegations that the company mishandled claims and levy additional penalties of up to $1.3 billion. The state accused PacifiCare of 133,000 violations from 2005 to 2007."
    —"PacifiCare fined record $3.5 million," by Gilbert Chan, The Sacramento Bee, January 30, 2008

How did they go about trying not to pay? Among the many misdeeds, the company is accused of wrongfully denying covered claims, failing to manage provider networks, making incorrect payments, making multiple requests for previously provided documentation, and failing to respond in a timely manner to member appeals and provider disputes.
—"Commissioner Poizner and DMHC Director Ehnes Take Historic Joint Action Against PacifiCare to Halt Broken Claims Payment Systems," Press Release, CA Department of Insurance, January 29, 2008

This is about a lot more than paper shuffling. The Sacramento Bee reports that among those hurt by PacifiCare's practices are:


  • A surgeon blocked from scheduling surgeries for six months.
  • Over 200 patients of a single pediatrician being incorrectly told he wasn't in the plan's network anymore.
  • One father fighting for 11 months to get claims paid for his autistic child, while his wife put off EKG stress tests.

-Read more in the "Foul Play" Archive.

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