When you have suffered a serious illness or injury, your first concern should be following your physician’s instructions and doing everything you can to speed your recovery. However, for too many injured or sick people, it seems that a disproportionate share of their energy ends up being channeled towards fighting with the insurance company over a claim that should be paid. In today’s day and age where all Americans must have health insurance or face fines and penalties, a significant number of New Yorkers and Americans who pay for health insurance coverage may find that when they truly need it, the insurance company will stall, delay, and otherwise engage in tactics to avoid paying on the claim.
One the biggest complaints about buying insurance often expressed by consumers is that they don’t have the information to choose a plan that fits their needs. New York publishes a wealth of information about insurance companies each year including prompt pay complaints, information about the number of internal and external appeals, and an overall consumer-sourced ranking. The 2014 edition of the rankings concerned with company performance in 2013, can provide insight into companies and their approach to business. For consumers, the first step to avoiding insurance issues after a car accident, slip and fall, or illness is to pick an insurer whose business practices you are comfortable with. If you still have an issue with your carrier’s practices, then contact the NYC personal injury attorneys of Sullivan & Galleshaw at 718-843-0300.
What NYC Insurance Companies Had the Most Complaints for Failure to Make Prompt Payments?
Under New York State law, health insurance companies are provided timelines by which they must pay claims or otherwise take appropriate action. Undisputed claims submitted electronically must be paid within 30 days and undisputed claims submitted on paper must be paid within 45 days. Furthermore, the insurance company must make a request for additional information from the medical facility or patient within 30 days of the claims receipt. Furthermore, in the case of a denial, it must be issued within 30 days. When companies fail to make timely payments on claims, consumers may complain and the New York Department of Financial Services will follow-up to determine if the complaint had merit.
For HMOs in 2013, Independent Health Association, Inc. received the highest ranking. The company had only 8 total complaints, 2 were concerning prompt pay issues, and none of the claims were upheld by DFS. To illustrate the difference in company’s approaches to claims, Easy Choice Health Plan of New York received the lowest ranking with 1,539 total complaints and 1,509 concerning prompt payment issues. 1,470 of those complaints were upheld. The company exited New York’s insurance marker at the end of 2014.
For non-HMO commercial health plans, there was a similar disparity between the highest and lowest ranked companies. American Progressive Life and Health Insurance was ranked first with only 5 total complaints and none regarding timely payment issues. Connecticut General Life Insurance Company was the lowest ranked with a prompt pay complaint ratio of 0.0607 meaning that nearly two of every three prompt pay claims was upheld. The average prompt pay complaint ratio was 0.0153.
Your Likelihood of Facing an External Appeal
New York DFS also tracks the need for members to file external appeals and the result of the appeal. Generally, covered individuals are entitled to file an external appeal after they have exhausted the internal appeals process. External appeals may be filed for a variety of reasons including non-coverage for out-of-network services, non-coverage on the basis that a treatment is not medically necessary and denial of coverage on the basis that a treatment is experimental.
The study tracked external appeals for 11 HMOs and 34 commercial health insurance providers. For HMOs, the average reversal rate was 37.66 percent. Genworth Life Insurance Company of New York had the highest reversal rate at the external appeals level at 64.29%. The HMO insurer facing the most external appeals, Empire HealthChoice HMO Inc., faced 165 external appeals and had a reversal rate slightly higher than average at 38.18%.
Of the commercial insurers, Empire HealthChoice Assurance, Inc. also faced the largest number of request for external appeals, but its reversal rate of 31.74% is below the average reversal rate of 34.86%. The companies with the highest reversal rate at the external appeals level are Freelancers Insurance Company, Inc., United Healthcare Insurance Company of New York, MVP Health Insurance Company. These three companies all have reversal rates at or above 50 percent.
Health Insurance Plans as Rated by New Yorkers
New York also provides information regarding the overall ranking of insurance companies. This overall ranking is based on complaints closed by DFS. Among HMOs, Independent Health Associations, Inc. was the highest rated insurer with 8 total consumer complaints and zero complaints upheld. It was the only HMO with zero complaints upheld. Among commercial health insurance firms and tied with 7 other firms, Genworth Life Insurance Company of New York was the highest rated commercial insurance company with zero complaints upheld.
Injured & the Insurance Company is Denying Coverage?
The New York City bad faith insurance attorneys of Sullivan & Galleshaw are dedicated to assisting the public by providing both information and legal services. To schedule a free legal consultation about suing your insurance company in NYC, call Sullivan & Galleshaw at 718-843-0300.