California’s Insurance Regulator Cites Health Plans for Failing to Provide Basic Health Care Services
California law is quite clear. State statutes and regulations require health plans to cover “basic health care services” among other requirements, but even this simple mandate seems beyond the willingness or ability of many health plans to meet. Here’s a look at some of the law’s most basic requirements, along with recent examples of how California insurers time and again fail to comply. If you have been unable to access the health care you need in a timely manner because of denials from your health plan, contact Gianelli & Morris in Los Angeles to speak with a California insurance bad faith lawyer.
The Scope of Basic Health Care Services in California
In Title 28, Section 1300.67, the California Code of Regulations sets out the scope of basic health care services that health plans must meet. This section quite plainly sets out the “basic health care services required to be provided by a health care service plan to its enrollees…” This broad requirement specifically includes the following types of services:
- Physician services provided by physicians licensed to practice medicine or osteopathy in accordance with applicable California law
- Consultation with and referral by physicians to other physicians
- Inpatient hospital services
- Outpatient hospital services, including physical therapy
- Diagnostic laboratory services
- Home health services
- Preventive health services
- Emergency health care services available and accessible 24/7
- Hospice services
The only requirement in the regulations is that these basic services must be medically necessary, and that requirement is where insurance companies most often hang their hat when denying care. But the fact is that doctors are not in the habit of prescribing unnecessary care. When insurance companies decide they know better than the doctor whether a procedure or treatment is medically necessary, you can bet they are looking at their financial bottom line and not at what’s best for the patient.
Health Plans Are Failing Patients
The California Department of Managed Health Care (DMHC), through its Office of Enforcement, investigates alleged violations of California’s health care laws. The office prosecutes violators in administrative actions, administrative hearings, and even in court. When the DMHC finds that the law was violated, it takes a variety of actions, typically by assessing administrative penalties and issuing cease and desist orders.
The DMHC maintains a database of enforcement actions taken against insurers. On any given day, you can search the database and find a host of actions taken against Anthem Blue Cross, Aetna, Carelon, Health Net and others for violations of Basic Health Care Services, such as:
- 67(a) – Failure to provide coverage for medically necessary physician services
- 67(d) – Failure to provide coverage for medically necessary diagnostic laboratory services
- 67(f) – Failure to provide coverage for medically necessary preventive health services
- 1367(i) – Failure to provide medically necessary basic health care service
- 03 – Failure to provide Timely Access to Care for in-network (and when not available) out-of-network providers
- 4(a) – Failure to provide 24-hour access for enrollees and providers to obtain timely authorization for medically necessary care in emergency situations
…just to name a few.
These enforcement actions are frequently accompanied by fines of $10,000, $50,000, and higher. Unfortunately, for companies like Anthem Blue Cross, whose value far exceeds $100 billion, a $50,000 fine seems to offer little in the way of deterrence, as violations continue to crop up month after month.
Good Faith? Bad Faith? No Faith in the System?
Legitimate disagreements over treatment can be expected, even if they cause a delay in care to work out. As long as the insurance company responds timely and makes its decisions within statutorily required timeframes, it can be considered to be acting in good faith. But when they fail to respond in a timely manner (or at all), or when all they do is look at the costs of a service without reviewing the request from a therapeutic perspective, then the insurer is not fulfilling its duty to process claims in good faith.
In cases like these, pursuing a claim for insurance bad faith might be your best or only recourse for getting the care you need and getting it paid for according to the coverage you’ve bought and paid for. A bad faith claim can also compensate you for other costs and harm you’ve incurred by a bad faith denial or delay. In some cases, punitive damages are also appropriate to hold the insurer fully accountable, prevent future abuses, and set an example for other insurance companies in the field. An experienced bad faith insurance lawyer can help by pursuing justice on your behalf with the required skill and know-how.
Contact California Insurance Bad Faith Lawyers at Gianelli & Morris
At Gianelli & Morris, holding health plans accountable for bad faith insurance practices is what we do. If you have been unfairly treated by your health plan in California, contact our Los Angeles law office for a free consultation to find out how we can help.
