Conn. AG Urges Release of Audit on Health Insurers’ Coverage Denials

Connecticut Attorney General Richard Blumenthal said his office has received several reports of health insurance companies denying coverage based on questionable conclusions that patients’ medical conditions pre-existed their insurance policies.

Blumenthal urged that the Department of Insurance finalize and release an audit that he requested Acting Commissioner Susan Cogswell to launch more than four months ago.

The audit, which Blumenthal said is necessary for him and the General Assembly to take enforcement and legislative action to stop potentially illegal or improper denial of vital health insurance coverage, has yet to be released.

Complaints to Blumenthal’s office involve Assurant Health Insurance’s (a.k.a. Fortis and John Alden Company) retroactive or “look-back” procedures used to bar coverage on the basis that patients’ conditions pre-existed policy onset dates.

“Compromising coverage of catastrophic illnesses is unconscionable and unacceptable,” Blumenthal said. “The Insurance Department cannot delay this audit any longer – now more than four months old. Its results are vital to coverage for life-saving medical treatment.”

Blumenthal described two of more than a dozen cases under review by his Health Care Advocacy Unit:

A 34-year-old woman was diagnosed with Hodgkin’s Lymphoma one month after her enrollment in a six-month policy underwritten by Fortis Health Insurance. During a post-enrollment diagnostic visit, the woman recalled experiencing mild shortness of breath while exercising some six months prior to her doctor’s visit. Fortis, in seeking to deny coverage, concluded that the shortness of breath she recalled during a single workout six months prior to enrollment constituted a pre-existing condition because the symptom should have caused her to seek medical treatment prior to enrollment.

Another woman was diagnosed with a skin condition weeks prior to insurance enrollment. The patient was covered by a prior Assurant term policy at the time of this diagnosis. Along with the diagnosis and issuance of a topical prescription, the doctor ordered a battery of tests that, subsequent to enrollment, yielded results that prompted him to recommend further assessment. All of these events evolved without undue medical delay. Further assessment yielded a diagnosis of cancer, requiring intensive, expensive and life-saving treatment – all covered benefits under the policyholder’s insurance contract. In an effort to deny coverage, claiming a pre-existing condition was knowable, Assurant has argued that this patient should have sought medical care before enrollment, even though she did; that the patient received medical advice regarding the condition prior to enrollment, even though her doctor had diagnosed a completely different and distinct condition other than cancer; and that a reasonable doctor should have diagnosed the cancer prior to enrollment.

Source: Conn. Attorney General Blumenthal