by When Colleen Henderson’s three -year -old daughter complained about pain when using the bathroom, the doctors wiped them as urinary tract infection or constipation, frequent diseases in the pottery training years.
However, Henderson suspected that it could be something worse and asked for an ultrasound. The doctor and the ultrasound technician told her that her insurer would not cover it Unitedhealthcare, but Henderson decided to do it anyway and stated her credit card of $ 6,000. Then came the message: In the bladder of her toddler there was a tumor in grapefruit size.
That was in 2008. In the next five years, said Henderson, a lengthy fight against Unitedhealthcare for the payment of the specialists, who finally diagnosed and treated the rare condition of her daughter, inflammatory pseudotumor. It appealed against non -unsuccessful hospital stays, operations and medication against the insurer and the state supervisory authorities. The family from the Sacramento region collected more than $ 1 million in medical debts because Unitedhealthcare unnecessarily communicated their treatments recommended by doctors. The family explained bankruptcy.
“If I hadn’t fought a tooth and nail on every step of the way, my daughter would be dead,” said Henderson, whose daughter finally recovered and is now a flourishing 20-year-old junior at Oregon State University. “You pay a lot of money to have health insurance and hope that your health insurance is in the foreground, but that doesn’t happen at all.”
While insurance refuses are on the rise, surveys show only a few Americans. Different analyzes have shown that many of those who escalate complaints to regulatory supervisory authorities successfully increase rejections (in contrast to the Hendersons). Consumer representatives and political decision -makers say that this is a clear drawing insurance company who routinely refuse to provide care that they shouldn’t. Now a proposal in California legislation is trying to punish insurers who repeatedly make the wrong call.
While the measure, SB 363, would only cover about a third of the insured Californians, whose health plans are regulated by the state, experts say that it could be one of the bold attempts by the nation to contain the rejection of the health insurer – before and after It is available. And California could become one of just one of only handful of states in which insurers must disclose refusal to refuse and argument. Data that the industry often looks at in proprietary information.
The measure also tries to force insurers to be more sensible with rejections by punishing up to 1 million US dollars per case if more than half of the appeals submitted to the supervisory authorities are canceled in one year.
In 2023, state data showed that around 72% of the appeals to the Department of Managed Health Care, which regulated the vast majority of health plans, led to the initial rejection of an insurer.
“If you have health insurance, you should have confidence that this will cover your needs of healthcare,” said Senator Scott Wiener, the Democrat of San Francisco, who introduced the law. “You can only delay, deny, hinder and in many cases avoid covering medically necessary care, and it is unacceptable.”
A spokesman for the California Association of Health Plans rejected a statement and said the group still checked the Bill language. Elana Ross, spokeswoman for governor Gavin Newsom, said that his office generally does not comment on any outstanding laws.
State legislators are concerned about the state costs of the health of consumers and have increasingly searched for ways to check whether insurers pay claims fair.
In 2024, 17 countries issued laws to prior approval of care by private insurers, according to the national legislation of the state conference. For example, Connecticut, which one of the most robust laws on the disclosure of rejection rate has, publishes an annual report in which the number and percentage of claims that every insurer has refused, as well as the share that ultimately reversed is described. Until recently, Oregon published similar information than the requirements for state disclosure met.
In California there is no way to know how often the insurers refuse to provide care, which health experts are particularly worrying, since mental health care among children and young adults reaches the crisis level. According to Keith Humphreys, a professor of health policy at Stanford University, it is easier to refuse mental health care, since a diagnosis of, for example, depression can be more subjective than that of a broken limb or a cancer.
“We think it is unacceptable that the state has absolutely no idea how big the problem is,” said Lishaun Francis, Senior Director of Behavioral Health at The Advocacy Group Children now, sponsor of the legislation.
As part of Wiener’s proposal, private insurers, who were regulated by the State Ministry of Health and/or the Ministry of Insurance, would have to submit detailed data on rejections and appeals. You would also have to explain these rejections and report the results of the appeals.
For appeals that manage to the independent medical review process of the state, which is described as IMR, insurers whose rejection of more than half of the time will be lifted would be exposed to amazing punishments. The first case that brings a company over the 50% neck would trigger a fine of $ 50,000, with a penalty between 100,000 and $ 400,000 in dollars for one second. Everyone would cost $ 1 million afterwards.
If the measure is adopted, the measure would cover around 12.8 million Californians for private insurance. It does not apply to patients in Medi-Cal, the state medicaid program or medicar, and it would rule out self-insured plans that are offered by large employers who regulate the US Ministry of Labor and cover around 5.6 million Californians.
After killing the CEO of Unitedhealthcare, the expression “Deny and Delay” continues to be reverberant in the health industry in the entire healthcare industry in December. In a survey by Norc at the University of Chicago, shortly after the attack, 7 out of 10 people stated that he was refusing rejections for health insurance and profits by health insurance companies who were of a lot or moderate responsibility for Thompson’s death.
After Thompson’s death, Unitedhealthcare said in statements that “very inaccurate and strongly misleading information” about the way the company treats claims and that insurers who are heavily regulated “usually have low to medium -sized digits” .
Wiener called Thompsons killed a “cold -blooded assassination attempt”, but said that his draft law was created from a closer proposal that had failed last year to improve mental health insurance for children and adults under the age of 26. Long -fluctuated anger that many Americans keep on the practices of health insurers and the urgent need for reform.
Humphreys, the professor of Stanford, said that the US health system creates strong financial incentives for insurers to refuse care. And he added that state and state punishments are poor enough to be written off as business costs.
“The more you deny you, the more money you make,” he said.
Large employers are increasingly starting to accept language in contracts with claims administrators who would punish insurers for the approval of too many or a few claims, said Shawn Gremminger, President of the National Alliance of Healthcare Commes Coalitions.
Gremminger mainly represents large employers who finance their own insurance, which are regulated by the state and are excluded by Wiener’s Bill. But even for so -called self -financed plans, it can be almost impossible to determine the refusal rates for the insurance companies that have only been set to manage claims, he said.
While the legislation could be too late for many families, said Sandra Maturino from Rialto, she hopes that the legislators will tackle insurance conservation so that other Californians can avoid the saga that she ended in order to treat her niece.
She adopted the girl, 13 after her sister died. Her niece had long struggled with self -harm and violent behavior, but recommended the inpatient psychiatric care as a therapist, her insurer Anthem Blue Cross would only cover it for 30 days.
Maturino, Maturino said for more than a year, her niece was incorporated and extended in institutions and advice because her insurance would not cover a long-term stay. The doctors tested a laundry list of prescription medication and doses. None of it worked.
Anthem refused to comment on this story.
In contrast to so many others in similar situations, Maturino was finally able to fix the situation. She asked the adoption agency for help, and she covered the costs for her niece’s stay in a living program in Utah, where she was diagnosed with a bipolar disorder and had been treated for a year.
Maturino said she didn’t have the energy to address the Anthem. “I would not wait for the insurance to kill her or to hurt someone,” said Maturino.
Kff Health News is a national news editor Kff – The independent source of health policy research, surveys and journalism.
This story originally appeared in the Los Angeles Times.
