Customer angry over bad insurance information

HUNTINGTON WOODS, Mich. – Helene Phillips of Huntington Woods is in her early 60s and has been blessed with good health for most of her life.

Sadly, that changed last October.

"I had a subdural hematoma and I had to have emergency brain surgery," she told Ruth to the Rescue.

As Phillips struggled to get back to 100 percent, she was advised to see a neurologist. She did what many of you would do. She asked for referrals and checked with her insurance company to see if the doctors she was considering were in her network.

"I called my insurance carrier HealthPlus on the 800 number," she said.

According to Phillips, the HealthPlus representative who took her call told her the doctors she was considering were in her network. She started seeing a neurologist, but months later received a bill that said the doctor was actually out of network. She called Health Plus to demand some answers.

"Then they go on and say while we regret that you received incorrect information customer service representatives are not authorized agents," she said.

That didn't make sense to Phillips. How could the people manning the 800 number not be required to give out correct information?

"These employees are trained. They have computers ..." she said.

Fighting the company, appealing for help

Phillips followed the appeals process with HealthPlus to no avail. Then, she filed a complaint with the state's Department of Insurance and Financial Services. HealthPlus never disputed the wrong information was given, but this is what the state of Michigan wrote to Phillips:

"While other insurers in similar circumstances have accepted responsibility for the errors of their employees and made equitable adjustments to claims payments, the director cannot compel health plus to do so."

Phillips was stunned that the state couldn't force HealthPlus to do what she considered the right thing. She says she was being charged about $400 extra because of the bad information. Feeling she'd run out of options, Phillips contacted Ruth to the Rescue for help.

After Ruth to the Rescue contacted HealthPlus, Phillips received a new letter in the mail. She was happier to read this letter aloud, "After careful review of the insurance commissioners response to your issue, we have reversed our decision."

Now, the company will pay the doctor, although just this one time, and the letter confirmed the doctor was out of network. The letter also reads, "We regret that you have had a negative experience and we appreciate you bringing this issue to our attention."

She found it interesting that after months of appeals the decision was now changed.

"They knew that I contacted Channel 4, and it's only after all that, that lo and behold they've come back and decided to stand behind what their employee told me to begin with," she said.

Phillips is hoping other insurance companies are also watching.

"I would hope it sends a big message to the industry that they should stand behind what their staff, who they have trained, tells their members."

HealthPlus statement:

Due to privacy concerns, HealthPlus is unable to comment directly on the complaints of any customer. The company did email Ruth to the Rescue this statement:

"Member privacy is a priority to the HealthPlus team and protected by federal law through the Health Insurance Portability and Accountability Act of 1996. Therefore, I cannot confirm a member's status with the company or comment on any particulars of service and care.

Here's what I can tell you. The HealthPlus team works very hard to provide unparalleled customer service. Part of that service includes a grievance procedure for members who wish to dispute how we've processed a claim. Typically, we find acceptable member solutions during this process. But sometimes we don't.

And sometimes, we make mistakes. When that happens, we reach out to the member and attempt to make it right, use the event as a lesson and, when we can, adjust how we work. It's part of our dedication to continuous quality improvement.

Every day, for our members and providers and the communities they serve, the HealthPlus team recommits to the company's mission of delivering health and wellness benefits of the highest value. Every day we work hard to forward the HealthPlus vision of healthier communities."

State of Michigan response:

Some consumers may be wondering what they can do if they're caught in a similar situation, especially if the government cannot compel an insurance company to stand behind information shared by customer services representatives. A spokeswoman for the Department of Insurance and Financial Services reminded consumers they can also see relief through the court system, and she released this statement about the Phillips case:

"This consumer took all of the correct action to confirm that the provider in question was in the plan network before moving forward with services. It is unfortunate that the consumer could not rely on that information given to her," said DIFS Director Pat McPharlin. "Going forward, it is important to say that the health insurance industry is constantly changing and consumers need to be knowledgeable of their plan as most health carriers offer several different plans and some plans may have limited provider networks. If consumers have a dispute with their health insurer they are encouraged to call the DIFS Office of Consumer Services to file a complaint and help with the appeal process at 877-999-6442."


About the Author: