Copyright 2009 Strafford Publications, Inc.All Rights Reserved Insurance Law & Litigation Week

February 23, 2009

Pg. 36

479 words


Health plans should make every effort to resolve coverage disputes with members; James P. Jacobson, To Pay or Not to Pay, That Is the Question: Coverage Disputes Between Health Plans and Members, 29 Hamline J. Pub. L. & Pol'y 445 (2008)

Health plans are vilified when they fail to cover needed care or make mistakes that are costly to members. But while there may be the perception that health plans frequently fail to provide the coverage members expect, most claims are paid promptly and with no inconvenience to patients or their families. However, when coverage disputes do arise, they are stressful for members who may also be experiencing health problems.

James P. Jacobson outlines both health plans' and members' responsibilities when coverage is in dispute and stresses that health plans should try to resolve coverage disputes as promptly as possible. The author recognizes the difficulty in providing members with appropriate coverage for needed care while containing costs, under pressure from employers who typically pay the premiums in the U.S. system.

While members may have wide discretion in choosing doctors and selecting which tests, procedures and medications they need or want, there will be limitations, restrictions and exclusions in the members' coverage documents. These coverage restrictions often form the basis of disputes between health plans and members.

Coverage disputes can develop over a wide variety of issues. Common types of disputes include requests for coverage for procedures that health plans consider experimental and requests for coverage for procedures that health plans consider cosmetic as opposed to medically necessary. Other common disputes include requests by members to go to non-network providers but receive benefits at the in-network benefit level.

Health plans can take steps to avoid disputes that lead to litigation and expense. Certain guidelines may be helpful in avoiding coverage disputes with members and in resolving disputes when they do arise. Health plans should provide clear information to members and be as responsive as possible when working with members to determine coverage or resolve disputes.

The author suggests that health plans resolve mistakes in the member's favor when a dispute is the result of misinformation provided by the health plan's representative. In addition, health plans must strive to treat members in a consistent manner, while taking into account each member's individual circumstances, needs and concerns.

Under our current fee-for-service system, coverage disputes will continue to occur between health plans and their members. There are certain responsibilities on both sides in avoiding and resolving coverage disputes. As pressures continue to mount on health plans to control costs and keep premiums affordable, the number of disputes is likely to grow.


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February 24, 2009

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