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Madison's unhappy HMO customers: 28 complaints from the Wisconsin Office of the Commissioner of Insurance
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Isthmus asked the Wisconsin Office of the Commissioner of Insurance to see all complaints filed against health care insurance providers by Madison-area residents from July 1, 2008, to June 30, 2009. For technical reasons, the office said it was unable to isolate complaints based on place of origin for Preferred Provider Plans (like Blue Cross Blue Shield), just for HMOs. It also declined to provide access to cases that are still regarded as "open."

In all, the records for 28 complaints were provided and reviewed at the OCI's offices. What follows are summaries of each complaint. Names are used in cases where the complainants consented. Initials and other pseudonyms are used on request, or in cases where attempts to contact the complainants were unsuccessful.

Verdicts have been assigned where possible based on outcome and OCI's role. Of the 24 cases that seemed clear enough to call, eight had satisfactory results, while 16 were unsatisfactory.

1. 198830 - T.F.

Fitchburg 53711

Complaint received: 7/2/08

File closed: 8/15/08

Complaint against: Unity Health Plans Ins. Corp.

Official reason and disposition: "Renewal With Altered Terms," "Contract provisions"

Problem: Complainant T.F. alleges that Unity "violated a number of provisions of Wisconsin law" by sending out an amendment to subscribers excluding coverage for bone-anchored hearing aids, then assuring subscribers on renewal that "no changes have been to your benefits for the upcoming year." The complainant spells out state statutes against insurers providing misleading information or changing terms of coverage without giving notice at least 60 days prior to the renewal date.

OCI action: Insurance examiner Pamela Ellefson sends Unity the complaint along with a form letter asking it to reply to the complainant within 10 days and to OCI within 20 days.

Company response: Unity says the amendment did not change the terms of coverage but was sent "for the sole purpose of clarifying coverage." Says the policy has always excluded coverage for bone-anchored hearing aids.

Other pertinent information: The actual amendment says "The certificates of coverage are amended to add the following exclusions...." T.F., in a follow-up letter to OCI, points this out and charges "Unity is engaging in doublespeak. If the existing policy already excluded the hearing aid, there would be no need to issue an exclusionary amendment. Unity wants to have it both ways."

Outcome: Ellefson closes the file, with standard form-letter language: "Based on the information provided, it appears the insurance company did not violate an insurance law or regulation with respect to the issued raised in your complaint. Our office has limited authority to resolve complaints when there has been no apparent violation of the Wisconsin insurance laws."

Verdict: Unsatisfactory; complainants' goals were not met.

2. 199097 - R.H.

Madison 53713

Complaint received: 7/14/08

File closed: 1/28/09

Complaint against: Group Health Cooperative of South Central Wisconsin

Official reason and disposition: "Contract Termination," "Information furnished"

Problem: R.H. tore his right calf muscle on 7/10/03, while laid off from his employer. Was advised to get a custom molded ankle brace. First checked with GHC to make sure it would be covered. GHC sent R.H. a letter dated Dec. 11, 2003, stating: "This APPROVAL letter confirms AUTHORIZATION for the services outlined in this referral," the custom molded ankle brace. R.H. was fitted for the brace and picked it up on 12/19/03. The claim filed by the brace maker, Aljan Co., was subsequently denied on grounds that R.H.'s employer, Madison-Kipp, had terminated his health coverage with GHC, as of Dec. 6, 2003. R.H. received a bill for $818.

OCI action: Sends GHC the complaint along with a form letter asking it to reply to the complainant within 10 days and to OCI within 20 days.

Company response: GHC says the claim for the brace was incurred after R.H.'s "termination of coverage date." Notes that the 12/11/03 letter of "APPROVAL" and "AUTHORIZATION" also contains language advising that "this referral is not a guarantee of your eligibility or benefits under your health plan." And it says R.H. failed to file a grievance over the denial within 180 days, as required. In a separate letter to R.H., GHC says that it received notice from Madison-Kipp on 12/12/03 -- after authorizing the brace -- that R.H. coverage was terminated effective 12/6/03.

Other pertinent information: Records show that Aljan Co. contacted GHC on 12/8/03 and verified that R.H. was "covered at 100%" for the brace. R.H. disputes the stated reason for his being cut off from health insurance -- that he had been on a medical leave of absence for six months -- saying he was only on leave four months at the time of his termination. He adds that had he known anytime prior to getting the brace on 12/29/03 that his coverage was terminated, he would not have gotten the brace.

Outcome: OCI examiner Marcia Zimmer sends a letter to R.H. noting that GHC's response "indicated that your coverage had been canceled by your employer" and that there was no apparent violation of any insurance law or regulation.

Epilogue: Contacted by Isthmus, R.H. implied that the situation was not yet resolved but declined to provide additional information.

Verdict: Unsatisfactory.

3. 199312 -- D.W.

Madison 53704

Complaint received: 7/28/08

File closed: 9/29/08

Complaint against: Physicians Plus Ins. Corp. and Auxiant

Official reason and disposition: "Coordination of Benefits," "Claim settled"

Problem: Daughter, who is covered through D.W.'s plan, went to Meriter Hospital on 12/16/07. Daughter also has coverage through father's insurance company, Auxiant. The couple's divorce decree says both parents must provide health coverage for their daughter but does not specify who is the primary. Now both companies are refusing to pay $1,239.61 bill for Meriter visit; Meriter has turned the matter over to a collection agency. D.W. to OCI: "It's absolutely absurd to pay out of pocket when two insurance companies are involved. Can you please help me?"

OCI action: Sends Physicians Plus the complaint along with a form letter asking it to reply to the complainant within 10 days and to OCI within 20 days.

Company response: Physicians Plus says "The reason for the denial was due to our not receiving proper coordination of benefits (COB) information from our insured." Says file has now been updated and it will update its records to indicate that Physicians Plus is the primary, under the so-called birthday rule, an informal rule among insurance companies that says the parent whose birthday comes first in the calendar year bears primary responsibility.

Outcome: OCI examiner Pamela Ellefson writes D.W. to say its review "indicates your complaint has been resolved."

Epilogue: D.W.'s listed phone is disconnected and she did not respond to a letter.

Verdict: Satisfactory; complainants' goals were met.

4. 199607 -- K.M.

Madison 53714

Complaint received: 8/8/08

File closed: 10/16/08

Complaint against: Dean Health Plan Inc. and Blue Cross Blue Shield

Official reason and disposition: "Access Problem -- HMO," "Information furnished"

Problem: Complainant K.M. has been going to Dean Clinic for decades, including some visits in early 2008; says she was not told that Blue Cross Blue Shield had stopped using Dean as a PPO (Preferred Provider Organization). She learned of this only after her employer's enrollment deadline for choosing health plans. The companies, she says, "have denied me the right to information to make a change in my insurance." Dean wants K.M. to settle her $1,718 balance.

Other pertinent information: K.M. says Blue Cross Blue Shield sent her a new sticker for her medical card at the start of 2008 but never said it was dropping Dean as a PPO; and that Dean never told her either. "I've never known any business that can just change a policy [without giving notice]. Especially when it [what the customer must pay] goes from zero to thousands of dollars.

OCI action: Sends Blue Cross Blue Shield the complaint along with a form letter asking it to reply to the complainant within 10 days and to OCI within 20 days.

Company response: Blue Cross/Blue Shield of Wisconsin (Anthem) says K.M. is insured under Blue Cross Blue Shield of Illinois. "We consider this complaint closed and it will not count against Anthem in your annual report of consumer complaints."

OCI follow-up: Examiner Nitza Pfaff notifies K.M. of the address of the Illinois Commissioner of Insurance. She also sends Dean Health Care her complaint along with a form letter asking it to reply to the complainant within 10 days and to OCI within 20 days.

Company response: Dean says "Our records indicate that [K.M.] did not have health coverage with Dean Health Plan when her charges were incurred." It adds that Pfaff confirmed in a phone conversation that "the complaint was sent to DHP in error" and requires no response.

Outcome: No further information in file.

Verdict: Unsatisfactory.

5. 201185 -- D.K.

Madison 53705

Complaint received: 10/22/08

File closed: 4/21/09

Complaint against: Dean Health Plan Inc., Wisconsin Physicians Service (WPS)

Official reason/disposition: "Claim Not Paid," "Information furnished"

Problem: Complainant D.K.'s insurance coverage through WPS was canceled on 6/30/06 when her hours were reduced at her place of employment. She and her husband were still covered through Dean. Her pharmacy, Walgreens, continued to bill WPS for prescriptions filled from 7/21/06 to 8/21/06, and WPS, not realizing that D.K. was no longer insured, paid the bills. It subsequently sought reimbursement of $872.48. D.K. says WPS should be getting the money from Dean.

OCI action: Sends Dean the complaint along with a form letter asking it to reply to the complainant within 10 days and to OCI within 20 days.

Company response: Dean says it is trying to learn more about what happened but notes that it requires claims to be submitted "within 60 days after services are rendered." It tells D.K. that if a bill were received "it would result in a denial for timely filing."

Other pertinent information: Dean, in a letters to OCI and D.K., says payment for the meds in the amount of $653.12 was sent directly to D.K., who cashed the check.

Outcome: OCI examiner Marcia Zimmer writes D.K., including the agency's standard language for an unsatisfactory result: "Although I understand and appreciate the frustration that caused you to contact us, I am unable to resolve your complaint to your satisfaction."

Epilogue: D.K. tells Isthmus she hadn't realized until she got this letter that the payment from WPS had come to her, and she must have cashed this check unwittingly. She now felt responsible for the situation and promptly paid $818 to settle her debt to WPS. Thus, D.K. ended up paying more than what she was reimbursed; Dean never had to pay anything; and Walgreens apparently took a loss on the meds. One more thing: OCI apparently never ascertained what happened. Says D.K., "They didn't really care, did they?"

Verdict: Unsatisfactory.

6. 201409 - J.P.

Madison 53704

Complaint received: 10/31/08

File closed: 12/8/08

Complaint against: Group Health Cooperative of South Central Wisconsin

Official reason/disposition: "Enrollment Problems," "Contract provisions"

Problem: J.P.'s 21-year-old son cannot get health coverage through dad's GHC policy because he is eligible for health coverage through his employer. The son is employed part time at the YMCA. Asks J.P., "Do you have any idea what a disincentive it is for a student who is trying to act responsibly? Do you have any idea how little he makes as a hourly employee at the YMCA? Do you have any idea what percentage of his income has to go toward paying his part of the premium?"

OCI action: Sends GHC the complaint along with a form letter asking it to reply to the complainant within 10 days and to OCI within 20 days.

Company response: GHC says its dependent coverage provisions "are, in general, more generous than many other group health plans. However, those provisions are not without limitation." The company say it will discuss the issue at its annual benefits review meeting.

Outcome: OCI examiner Pamela Ellefson writes J.P., saying GHC apparently "did not violate an insurance law or regulation." The letter closes with standard OCI language: "Thank you for bringing this matter to our attention. Your complaint is helpful to us in monitoring the insurance industry in Wisconsin."

Verdict: Unsatisfactory.

7. 201675 - A.F.

Madison 53704

Complaint received: 11/10/08

File closed: 1/8/09

Complaint against: Dean Health Plan

Official reason/disposition: "Claim Not Paid," "Billing Problem resolved"

Problem: Complainant A.F. went to UW Health Clinic on 10/13/04 with heart problem; was taken by ambulance to ER at UW Hospital. Never heard anything more. In April 2008, she was not allowed to schedule a test at UW Hospital due to an unpaid bill from 2004 "which I knew nothing about." Apparently the hospital had billed Unity, her former insurer, which didn't pay. At that time, A.F. had been employed by Dane County for three years and was insured through Dean. She denies getting calls or letters from UW Hospital about the matter, as it claimed. The hospital has turned the matter over to a collection agency. A.F. thinks it's Dean's responsibility to pay these bills.

OCI action: Sends Dean the complaint along with a form letter asking it to reply to the complainant within 10 days and to OCI within 20 days.

Company response: Dean says that by the time it was billed for these expenses in May 2008, payment was denied because the claim had not been filed in a timely manner.

Outcome: According to a note in the file, OCI insurance examiner Glen Navis spoke to a supervisor at UW Hospital about this matter and "argued...that when [A.F.] incurred this bill in 2004 she had Dean Care but UWH sent the bills to Unity and had never notified Angela that they were never paid." The next day, the supervisor relayed that UW Hospital officials "have decided to write off this $600 bill...and will notify the collection agency that this had been sent in error."

Verdict: Satisfactory.

8. 202003 - B.H.

Madison 53703

Complaint received: 11/17/08

File closed: 4/23/09

Complaint against: Dean Health Plan Inc.

Official reason/disposition: "Refusal to Insure," "Policy issued"

Problem: Complainant B.H. applied to Dean Health Plan for coverage; was denied due to a gastritis/agoraphobia-related condition, which she says is controlled by generic medications and entails no increased health risks.

OCI action: Sends Dean the complaint along with a form letter asking it to reply to the complainant within 10 days and to OCI within 20 days.

Company response: Dean agrees to rescind denial. Says it determined, based on its review, that "the debits points originally applied to medical conditions that causes denial...could be removed." B.H. is told her monthly premium will be $154.79.

Outcome: OCI examiner Marcia Zimmer says the matter has been "resolved."

Verdict: Satisfactory.

9. 202008 - Sandra Endlich

Madison, WI 53705

Complaint received: 11/17/08

File closed: 5/6/09

Complaint against: Dean Health Plan

Official reason/disposition: "Access Problem - HMO," "Coverage Problem resolved"

Problem: Was diagnosed with thyroid disease after three years of problems. Says the right test was never done. Once diagnosed, was told a referral to a endocrinologist may take as long as five months. Thinks she should be referred to an out-of-practice provider.

OCI action: Sends Dean the complaint along with a form letter asking it to reply to the complainant within 10 days and to OCI within 20 days.

Company response: Dean tells OCI that it has apologized to Endlich for the delay, and has scheduled an appointment for Feb. 27, '09 - a little more than three months after she complained about a possible five-month wait. Also says she will be placed on a list of people to be called in case of cancellation. Says that if Endlich "and her primary care physician feel she need [sic] to be seen by the endocrinologist earlier than her scheduled appointment, Feb. 27, '09, her primary care physician can submit a referral request to an out-of-network provider."

Outcome: OCI examiner Marcia Zimmer writes Endrich: "My review of the insurance company's response indicates your complaint has been resolved."

Epilogue: Endlich tells Isthmus she tried to be seen by an out-of-network provider but no referral was made. She ultimately did get in to see an endocrinologist sooner than she was told. This happened after she experienced additional complications, including adverse reactions to medications her primary physician prescribed, and ramped up the pressure on Dean to get in to see the endocrinologist: "I probably made 25 to 30 calls and I made a nuisance of myself and I got in sooner."

Verdict: Unsatisfactory, in terms of OCI's involvement.

10. 202564 - M.Y.

Madison 53713

Complaint received: 12/5/08

File closed: 2/6/09

Complaint against: Unity Health Plans Ins. Corp.

Official reason/disposition: "Experimental," "Information furnished"

Problem: Complainant M.Y. argues that Unity is wrong to refuse to cover vagus nerve stimulation (VNS) treatment for depression as "experimental."

OCI action: Sends Unity the complaint along with a form letter asking it to reply to the complainant within 10 days and to OCI within 20 days.

Company response: Says it has reviewed the matter and upheld its decision to deny coverage.

Other pertinent information: After M.Y. strikes out with appeals to Unity and his complaint to OCI, an independent review organization (IRO) company is hired to review the denial, as OCI rules permit. The IRO reaches the same conclusion, that the treatment is experimental and does not have to be covered. M.Y. then files an OCI complaint against the IRO, saying it contradicted itself in its ruling.

Outcome: OCI managed care specialist Barbara Belling writes M.Y. to say that while he continues to disagree with the decision that was made, there is nothing it can do: "Our office does not have the authority to make a judgment on the medical opinion of an IRO's peer reviewer."

Verdict: Unsatisfactory.

11. 202491 - E.R.

Madison, WI 53704

Complaint received: 12/5/08

File closed: 7/8/09

Complaint against: Group Health Cooperative

Official reason/disposition: "Policy Provisions," "Information furnished"

Problem: After midnight on 10/16/08, complainant E.R. took wife to emergency room at UW Hospital with chest pain. Tests showed she'd suffered atrial fibrillation. Was kept for observation but was released after 5 p.m. GHC charged a $75 ER co-pay that would not have been charged had she stayed overnight. Complainant says this was because of a lack of room availability and that not staying overnight saved GHC money. Wants GHC to cover co-pay.

Other pertinent information: E.R.'s letter says he told by a GHC representative that OCI "will dismiss [this complaint] outright for lack of merit" and that "this complaint will only result in insurance premiums costing more for everyone."

OCI action: Sends GHC the complaint along with a form letter asking it to reply to the complainant within 10 days and to OCI within 20 days.

Company response: GHC explains in 12/19/08 letter to insurance examiner Marcia Zimmer that the $75 co-pay is waived only if the patient is admitted to hospital and kept under observation for more than 24 hours.

Follow-up: Zimmer, in a 5/7/09 letter to GHC, asks for "proof that GHC verified" that a room was available, and explain how it complied with its policy if, as E.R. asserted, there was not. GHC replies that "there is nothing in the hospitals [sic] documentation, according to [a UW official], that [E.R.'s wife] was to be admitted but was not due to 'unavailable' room."

Further follow-up: Zimmer, in a 6/15/09 letter to GHC, asks for "written verification of the availability of the hospital room" for the E.R.'s wife. GHC says the hospital has confirmed that a room was available; otherwise it has overflow arrangements with Meriter and St. Mary's. It does not appear as though documentation was provided.

Outcome: Zimmer of OCI notifies E.R. in a letter dated 7/8/09 that she has "received the company's final response," and includes standard language that "Although I understand and appreciate the frustration that caused you to contact us, I am unable to resolve your complaint to your satisfaction." E.R. ends up paying the $75 co-pay.

Epilogue: E.R. tells Isthmus he's pleased with the role played by OCI: "It's a great service. They make the insurance companies respond. Otherwise, if you go to the insurance company they dismiss you."

Verdict: Unclear. Complainant's goals were not met, but he has positive view of OCI's involvement.

12. 203380 - Donna Fox

Madison 53704

Complaint received: 1/19/09

File closed: 3/30/09

Complaint against: Unity Health Plans Ins. Corp.

Official reason/disposition: "Refusal to Insure," "Coverage Problem resolved"

Problem: Complainant Fox is executive director of the Canopy Center (formally Parental Stress Center). Her group switched healthcare providers from GHC, which covered all employees who worked 20+ hours, to Unity, which said it would only cover employees who work 30+ hours per week. Fox says she now must "deny a staff person health insurance coverage on our group policy but I have no answer to give them when asked why. In these difficult economic times, it is disconcerting to know that an employer who WANTS TO provide coverage for all employees working 20+ hours is being denied the ability to do that without any sound reasoning behind it."

OCI action: Sends Unity the complaint along with a form letter asking it to reply to the complainant within 10 days and to OCI within 20 days.

Company response: Unity says state law says employees who work 30+ hours are eligible for health insurance; companies may have lower requirements, but Unity has decided not to. But in this case, the employee was erroneously included in the employee counts and so Unity says it will cut Canopy a break: "Although this employee would not normally be eligible for enrollment, because of the actions taken by Unity, this employee may remain covered under your group policy."

Outcome: OCI examiner Linda Low writes Fox to say the complaint has been resolved.

Epilogue: Fox thinks complaining to OCI maybe helped force Unity's hand, although she still feels as though she was never given a clear explanation for why the employee was not covered: "I kept trying to get a straight answer. They said, 'We don't have to so we don't.'"

Verdict: Satisfactory.

13. 203612 - J.G.

Madison, 53717

Complaint received: 1/23/09

File closed: 7/1/09

Complaint against: Dean Health Plan Inc.

Official reason/disposition: "Claim Handling," "Information furnished"

Problem: In November 2006, complaint J.G.'s son had an emergency appendectomy while away at college in Arizona. The surgery was pre-approved by Dean, which paid bills totaling more than $29,000. But Dean balked at paying $556.35 of a bill from one provider, saying it was waiting for an explanation. The provider has turned the matter over to collections, seeking to make J.G. pay. She thinks it's Dean's responsibility: "An insurance company should not pick and choose what they are going to pay when it comes to an emergency."

OCI action: Sends Dean the complaint along with a form letter asking it to reply to the complainant within 10 days and to OCI within 20 days.

Company response: Dean says it has received the matter and decided to uphold the denial. The claim, Dean tells J.G., "was paid correctly according to your policy." It suggests the charges it is refusing to pay amount to double-billing by the provider but says there is nothing it can do: "[The provider] is not a contactor provider with DHP and as such, DHP cannot contractually have then cease from billing you for the balance due of $556.35 on the claim."

Outcome: OCI examiner Marcia Zimmer notifies J.G. of the company's response and says there is nothing more the state can do.

Epilogue: J.G. tells Isthmus she ended up paying the $556 bill because, although her son was insured through her policy, the Arizona provider threatened to put the debt on his credit record: "Because I refused to pay it because it was Dean's job, it was going to go on his credit." And that would be a detriment to her son, now in medical school. As for the OCI's role, J.G. says, "I don't think they did much. I think they should have looked into it further." She had a subsequent bad experience with an insurance provider but this time didn't bother to file an OCI complaint: "I was just so fed up."

Verdict: Unsatisfactory.

14. 203715 - V.C.

Madison 53711

Complaint received: 1/27/09

File closed: 7/8/09

Complaint against: Physicians Plus

Official reason/disposition: "Contract Termination," "Coverage extended"

Problem: Complainant V.C. gave birth to a child 3/1/08, planned to quit job afterward. Was asked to stay on to train replacement. Didn't work out and left employment on 3/24/08. Was later told insurance was terminated on 2/29/08, ended up getting stuck with bills totaling more than $9,000. Thinks bills should be covered.

OCI action: Sends Physicians Plus the complaint along with a form letter asking it to reply to the complainant within 10 days and to OCI within 20 days.

Company response: Physicians Plus says V.C. was "erroneously advised" she was terminated on 2/29/08 when it was actually 3/31/08. Has been subsequently reinstated.

Outcome: OCI examiner Marcia Zimmer writes V.C. to say it appears that her complaint was satisfactorily resolved.

Verdict: Satisfactory.

15. 203948 - M.C.

Madison 53704

Complaint received: 2/4/09

File closed: 7/2/09

Complaint against: Group Health Cooperative of South Central WI

Official reason/disposition: "Exclusions," "Coverage extended"

Problem: Complaint M.C. needs a new prosthesis (obturator) "so I can eat without food and beverages going into my sinuses." Both without a cleft palate, he has a prosthesis now held in place by his teeth. But one of these teeth has come out, so the prosthesis rubs against his gums, causing sores. He can thus eat only soft foods, and has a hard time with raw vegetables, fruit and meat, to where he worries about getting diabetes from his high-carb diet. Says GHC has refused to pay for the treatment he needs.

Other pertinent information: Included with the complaint is a letter dated 5/29/08 from Dr. Mark Jackson of the Center for Oral and Maxillofacial Surgery in Madison, supporting M.C.'s request: "He now wears an obturator but has lost dental support for that. Our plan is for the placement of two osseo-integrated implants to support his prosthesis. This treatment is functional and not aesthetic."

OCI action: On 2/5/09, sends GHC the complaint along with a form letter asking it to reply to the complainant within 10 days and to OCI within 20 days.

Company response: GHC, in a 2/19/09 letter to OCI examiner Lynn Pink, states: "[M.C.]'s appeal received careful and considerable evaluation and it was determined, given the circumstances, that a compassionate approval was appropriate. We believes this resolves [M.C.]'s complaint."

OCI action: OCI examiner Pink sends 2/27/09 letter to M.C. saying his complaint has been resolved.

Follow-up: In a letter dated 3/27/09, GHC denies M.C.'s request for coverage of two implants, on grounds that he does not have coverage with GHC at time of service; says his coverage will end on 3/31/09.

OCI action: Pink sends GHC a letter 6/11/09 asking for its response.

Company response: Says M.C.'s coverage was terminated when he lost his job but it has arranged for him to obtain coverage under COBRA with no break in coverage.

Outcome: Pink writes M.C. to say her review shows the matter has been resolved. But there is nothing in the file to confirm that M.C. got the surgery he needed. Attempts by Isthmus to contact M.C. were unsuccessful.

Verdict: Unclear.

16. 204146 - G.C.

Madison, WI 53704

Complaint received: 2/10/09

File closed: 7/29/09

Complaint against: UnitedHealthcare of Wisconsin

Official reason/disposition: "Misrepresentation," "Disciplinary action recommended"

Problem: Complainant G.C. sends letter explaining that she received a call from a representative of Evercare, a.k.a. United Healthcare Insurance Co., saying it could help her save money on over-the-counter drugs. Was not told that co-payments were part of the deal, and has been "unable to cancel" the arrangement.

OCI action: Sends United Healthcare the complaint along with a form letter asking it to reply to the complainant within 10 days and to OCI within 20 days.

Company response: Submits a 6-page response to OCI dated 3/18/09 explaining its investigation into the substance of this complaint. It concludes that the agent made several incorrect representations and says its review team "is forwarding the allegations against the agent to the Corrective Action Committee for review." In a follow-up letter dated 5/16/09, it says the agent has been ordered to "retake the Evercare DH-POS Module" and review how benefits are impacted with his manager. Included are materials from United HealthCare regarding its investigation and findings.

Outcome: In April, OCI examiner Nitza Pfaff writes the company, asking for additional information. An OCI summary of complaints says "Disciplinary action recommended," as noted above. But there is nothing in the file to indicate that OCI is pursuing the matter.

Epilogue: OCI spokesman Jim Guidry says "our investigation is still going on."

Verdict: Unclear.

17. 204663 - Dawn Williams

DeForest 53532

Complaint received: 2/26/09

File closed: 7/22/09

Complaint against: Physicians Plus

Official reason/disposition: "Denial Of Claim," "Contract provisions"

Problem: Williams complains that Physicians Plus does not cover "the bariatric Lap Band Surgery I requested." She has severe arthritis and needs a total knee replacement; even short walks entail severe pain. But her doctors say she must lose 100 pounds before this surgery can be performed. And "I cannot lose weight because I cannot move around, let alone exercise because of the knee pain." Hence she first needs the bariatric Lap Band surgery: "My quality of life depends on these two surgeries."

Other pertinent information: The complaint includes letters from three UW Health physicians supporting Williams' need for these surgery. Writes one, "Dawn has tried a variety of measures to try to decrease her weight, and the next most logical option at the current time would be for her to undergo bariatric surgery."

OCI action: Sends Physicians Plus the complaint along with a form letter asking it to reply to the complainant within 10 days and to OCI within 20 days.

Company response: Informs Williams of the outcome of its grievance hearing, which she attended: "Physicians Plus will not...cover this surgical procedure." Also writes a letter to OCI: "The issue has now been reviewed by our grievance committee, and even though the issue was not resolved in favor of [the complainant], it has been resolved."

Outcome: OCI examiner Marcia Zimmer sends Williams the agency's standard letter saying its authority is limited and there is nothing more it can do.

Epilogue: Williams tells Isthmus she is continuing to fight for the knee surgery she so desperately needs, including by sending OCI additional information. As for how OCI has handled the matter to date, Williams says, "I don't think they handled it at all. It was just shuffled-through paper, pushed through the process. They need to step in and say, 'Hey, what can we do?'"

Verdict: Unsatisfactory.

18. 204892 - Pamela Selje

Madison 53711

Complaint received: 3/5/09

File closed: 6/9/09

Complaint against: Physicians Plus Ins. Corp., Blue Cross/Blue Shield (Anthem)

Official reason/disposition: "Coordination of Benefits," "Coverage Problem resolved"

Problem: Pamela Selje and husband Mark both carry insurance for her daughter (his stepdaughter). On 1/12/08 the daughter went to urgent care for suspected strep throat. Both Pamela and Mark's insurance companies - Physicians Plus and Blue Cross/Blue Shield, respectively - claim the cost of this visit is the other's responsibility. Pamela Selje asks OCI, "I would like you to determine which insurance company is primary so that this bill is paid."

Additional pertinent information: In the past, Mark's insurer, Blue Cross/Blue Shield (Anthem), has covered the daughter's medical expenses.

OCI action: Sends Physicians Plus a copy of the complaint along with a form letter asking it to reply to the complainant within 10 days and to OCI within 20 days.

Company response: Physicians Plus, in a letter to OCI examiner Kevin Zwart dated 3/30/09, says it has consulted with its attorneys as well as with "Julie Walsh and Michael Horneck of your office," and the bills were the responsibility of Anthem under the "birthday rule," which assigns primary responsibility to the parent whose birthday comes earlier in the calendar year.

Outcome: OCI examiner Zwart, in a letter to Selje dated 6/8/09, says that Physicians Plus has now determined that just the opposite is true - that because stepfather Mark did not officially adopt the daughter, and Pamela is the girl's biological mother, the primary insurer would be Physicians Plus. It is agreed that Blue Cross Blue Shield (Anthem) will be refunded for past coverage of the daughter's medical costs.

Epilogue: OCI spokesman Jim Guidry says "the decision to make Physicians Plus the primary insurer was due to the fact that the stepfather never officially adopted the daughter, meaning she didn't meet the definition of dependent in the policy." It remains unclear why OCI's staff earlier backed the opposite conclusion. Mark Selje tells Isthmus the couple has not received additional paperwork on the matter and assumes the bills were taken care of as promised.

Verdict: Satisfactory.

19. 205232 - Bill Lueders

Madison 53704

Complaint received: 3/19/09

File closed: 8/4/09

Complaint against: Group Health Cooperative of South Central Wisconsin

Official reason/disposition: "Claim Handling," "Information furnished"

Problem: Complainant Lueders switched to a new GHC plan on 1/1/09 and on 1/5/09 called to be paired with a primary care provider; GHC recommended that he come in for a visit to meet with the provider. During this visit, on 1/6/09, some health concerns were raised and a test done; blood was drawn the following day, as part of ongoing monitoring of existing conditions. Lueders is subsequently billed for the entire $589 cost, which he thinks should be covered under GHC's annual $500 allotment for preventative care.

OCI action: Sends GHC the complaint along with a form letter asking it to reply to the complainant within 10 days and to OCI within 20 days.

Company response: In letters to OCI and Lueders, GHC argues that its allotment for "preventative care" does not cover "testing for ongoing diagnosis or treatment of a condition." Also that the office visit was not covered because Lueders "presented" with health concerns.

Lueders response: Asks OCI to "Make GHC explain why it assures policyholders that it covers screenings [for various conditions] when in fact it does not cover tests done either for diagnosis or treatment. What other kind of screening is there?" He also informs OCI, repeatedly, about an apparent double charge for a given service.

OCI action: OCI examiner Marcia Zimmer sends GHC the response letter and asks it to respond. Asks no questions particular to the complaint. Does not ask GHC to explain what screenings it does cover.

Outcome: GHC ultimately admits it charged twice for the same service due to a "coding error," and removes it, with apology. The insurer does not further explain its confusing policy language. Zimmer writes Lueders to say there is nothing more the state can do.

Epilogue: Lueders pays the bill, minus the overcharge. He subsequently learns, in a discussion with GHC reps, that GHC considers any test done to monitor a known condition "diagnostic" and hence not covered as preventative care.

Verdict: Unsatisfactory.

20. 205142 - Peter Anderson

Madison 53705

Complaint received: 3/18/09

File closed: 4/20/09

Complaint against: Physicians Plus Ins. Corp.

Official reason/disposition: "Policyholder Service," "Information furnished"

Problem: Anderson: "Physicians Plus statement and explanation of benefits are written too cryptically to understand the particular health claim involved and, in the case of denials, the reasons for the denials." Anderson adds: "To find out what the statement refers to, therefore, requires a needless expenditure of time." He asks for the statements to be understandable.

OCI action: Sends Physicians Plus the complaint along with a form letter asking it to reply to the complainant within 10 days and to OCI within 20 days.

Company response: Physicians Plus says in a letter to OCI dated 4/10/09 that it has advised Anderson of its decision to "review the entire issue" and update its statements "to provide more clarity and specificity for our members. This internal project will begin immediately."

Other pertinent information: Physicians Plus, in reviewing Anderson's complaint, realizes that the bill it concerned was "denied in error." Anderson, who apparently couldn't understand the reason for the denial enough to question it, is told that he does not owe $106.20, as indicated.

Outcome: OCI examiner Lynn Pick notifies Anderson that his complaint has been resolved; there is no indication that it followed up to see if Physicians Plus actually took steps to make its statements clearer.

Epilogue: Anderson tells Isthmus he is angered at OCI's response: "The staff had zero inclination to make any logic out of the system." Physicians Plus declined to discuss the case, citing medical privacy laws, but says it has updated some of its "narratives" in billing statements. Anderson says his statements are still unclear.

Verdict: Unsatisfactory.

21. 205635 - Madison Surgery Center

Madison 53701

Complaint received: 3/30/09

File closed: 6/25/09

Complaint against: Dean Health Plan Inc.

Official reason/disposition: "Denial Of Claim," "Contract provisions"

Problem: The complainant, Darilyn Hill of the Madison Surgery Center, says it provided service to client J.T.J. on 3/27/08; sent bill to Dean on 4/10/08. Called on 6/26/08 to check on status; was told that no bill had been received. Resubmitted claim 7/26/08; it was denied due to untimely filing. Appealed denial and supposedly provided proof of original billing but was denied again, this time for having an invalid provider number. Tells OCI it thinks Dean should process the claim.

OCI action: Sends Dean the complaint along with a form letter asking it to reply to the complainant within 10 days and to OCI within 20 days.

Company response: In letter to OCI dated 4/20/09, says bill was initially denied due to invalid provider number and later for being submitted too late.

Outcome: OCI examiner Linda Low writes the Madison Surgery Center on 6/25/09 to say there has been no apparent violation and there's nothing more the state can do.

Epilogue: Lisa Brunette, a spokeswoman for UW Health (the Madison Surgery Center is jointly owned by three partners, two of them UW-related) says that, as a matter of policy, "If MSC [as opposed to a patient] has made a billing error, then MSC will not pursue the patient for payment." In other words, the center and not the patient would have taken the loss in this instance.

Outcome: Unsatisfactory.

22. 205647 - C.B.

Monona 53716

Complaint received: 4/1/09

File closed: 8/11/09

Complaint against: Group Health Cooperative of South Central Wisconsin

Official reason/disposition: "Policyholder Service," "Information furnished"

Problem: On 2/17/09 the federal government passed a COBRA subsidy as part of the stimulus plan. Complainant C.B. is on COBRA and thinks she's eligible for the subsidy. Says she's been unable to get information from her former employer or GHC regarding this subsidy. Thinks notification of eligibility is required.

OCI action: Sends GHC the complaint along with a form letter asking it to reply to the complainant within 10 days and to OCI within 20 days.

Company response: GHC tells OCI it's contacted C.B.'s former employer regarding this matter. Tells C.B., in a letter dated 4/16/09, that the employer has until 4/18/09 to notify her of any developments.

Outcome: OCI examiner Brian Baird writes to C.B., saying "My review of the insurance company's response indicated your complaint has been resolved." The file contains no further information on what happened.

Verdict: Unclear.

23. 205688 - Marilyn Townsend

Madison 53703

Complaint received: 4/2/09

File closed: 7/1/09

Complaint against: Unity Health Plans Ins. Corp.

Official reason/disposition: "Premium Notice/Billing Problems," "Information furnished"

Problem: Complainant Townsend is upset by insurer "unilaterally adding a 'paper fee' of $10 to its monthly premium" which can be avoided only if policyholder agrees to receive billing statements via email. Unity, in a letter, says it made the change "to help reduce the amount of paper mail you receive and help bring wellness to the environment." Townsend thinks Unity should offer a $10 discount for those willing to receive email statements, not impose a $10 fee on those who don't.

Other pertinent information: Townsend sees Unity's action as "a shakedown to get my email address" so it can be used for other purposes, which she does not want. She says in a letter to a Unity official: "Unity's approach to customer relations is one reason the populace is up in arms toward insurance companies and other corporate conglomerates. Have Unity executives not been reading the newspapers?"

OCI action: Sends Unity the complaint along with a form letter asking it to reply to the complainant within 10 days and to OCI within 20 days.

Company response: Unity tells OCI it treated Townsend's complaint as a grievance and discussed it at a hearing in April, which she declined to attend. Unity decided at this meeting to uphold its original billing fee.

Outcome: OCI examiner Linda Low writes Townsend to say it was "unable to resolve your complaint to your satisfaction." The letter from OCI also states: "There are no laws regarding companies charging billing fees." Also "no definition of premium in Wisconsin insurance law" and "no insurance law regarding the format used in a premium invoice."

Epilogue: Townsend tells Isthmus she decided not to fight the matter further. She is unhappy with how OCI handled her complaint: "I felt that they never came to grips with the issue I was complaining about." She was trying to make the case that the cost of billing ought to be included in her monthly premium. "I felt someone over there should have said to Unity: 'This doesn't make sense. You haven't demonstrated that you are entitled to this.'"

Verdict: Unsatisfactory.

24. 205694 - Emily Steinnagel

Madison 53716

Complaint received: 4/6/09

File closed: 8/24/09

Complaint against: Dean Health Plan

Official reason/disposition: "Underwriting," "Information furnished"

Problem: Complainant Steinnagel applied for private health insurance through Dean Health Plan 3/3/09; says her occasional migraines have been well-controlled for over a year by meds. Was declined by Dean on 3/16/09 because of headaches. Tells OCI: "I am now unable to apply to other health insurance plans because I have been denied coverage [by Dean]. I was not offered any appeals process. My doctor tried to call the Customer Service Department to see what she could do and it seemed as though they refused to listen." Asks for Dean to review med records: "I am a healthy 22-year-old female. I should be able to find insurance."

OCI action: Sends Dean the complaint along with a form letter asking it to reply to the complainant within 10 days and to OCI within 20 days.

Company response: Dean tells OCI it "received the complaint and the decision is to uphold the current denial based upon the information received on the application and during the phone interview." Suggests that if Steinnagel gets a negative MRI test result within a month, she "may request for underwriter to reconsider her application. She would be required to submit payment of the first month's premium and she may be required to sign and date the application again."

Outcome: OCI examiner Marcia Zimmer informs Steinnagel that the state is "unable to resolve your complaint to your satisfaction." The letter also says: "Companies may decide not to insure an individual, charge an extra premium, or place an exclusionary rider on the policy for a particular medical condition. The company's decision must be based on sound actuarial principles or be supported by actual or reasonably anticipated experience."

Epilogue: Steinnagel tells Isthmus she indeed had an MRI and it came back negative, which made her more optimistic about finding coverage. She decided not to reapply with Dean and subsequently obtained a short-term health policy though another insurer which "is not as strict on pre-existing conditions." She notes that her interaction with OCI did nothing to change Dean's decision to deny her coverage: "Really nothing came of my complaint."

Verdict: Unsatisfactory.

25. 205880 - V.H.

Madison 53719

Complaint received: 4/10/09

File closed: 8/11/09

Complaint against: Physicians Plus Ins. Corp.

Official reason/disposition: "Claim Handling," "Claim settled"

Problem: Complainant V.H., a student covered under her mother's policy, was admitted to ER in Minneapolis in 2005 and the bills were eventually covered by Physicians Plus. She was admitted twice more in 2007, to the same ER. One of the visits was covered, the other not. Physicians Plus purportedly declined to pay because she failed to notify Physicians Plus on her ER visit within 48 hours, as required. The bills for this visit total $8,000.

V.H. says she was "in no condition to place a phone call to the provider to ensure that the services were covered" during the three-day hospitalization that was not covered. Says her attempt to talk to Physicians Plus about this lack of coverage "was dismissed in a very unprofessional manner." Thinks Physicians Plus should cover these costs.

OCI action: Sends Physicians Plus the complaint along with a form letter asking it to reply to the complainant within 10 days and to OCI within 20 days.

Company response: "After review of the information provided, we have decided that Physicians Plus will pay these claims."

Outcome: OCI examiner Brian Baird, in a letter to V.H., says the office's review indicates the complaint has been resolved."

Epilogue: V.H. tells Isthmus the insurance company followed through on what it said it would do, making payments to the original service providers. Is still waiting for some of these providers to refund the money they received earlier from her.

Verdict: Satisfactory.

26. 206418 - Dennis Gordon

Madison 53703

Complaint received: 4/30/2009

File closed: 8/2/09

Complaint against: Physicians Plus Ins. Corp.

Official reason/disposition: "Group Continuation Not Offered," "Policy not in force"

Problem: Gordon was insured through Physicians Plus while employed at Platinum Concepts; his coverage was terminated without notice on 4/30/06. He learned of this in February 2007 while a patient at St. Mary's. Thinks employer should have to pay bills for his hospital stay.

OCI action: Sends Physicians Plus the complaint along with a form letter asking it to reply to the complainant within 10 days and to OCI within 20 days.

Company response: Physicians Plus tells OCI that Gordon's coverage was terminated because his employer stopped paying premiums. He was purportedly never informed of this, and sought treatment at St. Mary's in February 2007 while "in extreme pain" from a hip fracture. Physicians Plus also says that, because St. Mary's was not a participating provider, "his claims would have been denied even if his coverage had been in effect." Also that he is ineligible for coverage under COBRA, a program for employees who lose their jobs.

But, Physicians Plus says, it has decided to offer Gordon a conversion policy that would be retroactive to his date of termination. All he would need to do is pay the full cost of his premiums going back to that time - a total of $15,860.

Other pertinent information: Physicians Plus tells OCI it sent notification to Gordon's employer "and instructed him to notify his employees of the group's termination of coverage and the opportunity of those employees to elect coverage under a conversion plan. We were unaware that Mr. Gordon's former employer did not properly notify his employees until we received Mr. Gordon's complaint to your office." And when the insurer tried calling the employer, Brian Bowling of Platinum Concepts, it found that his business and home phone were disconnected. (Bowling, the former owner of Platinum Concepts, was recently indicted in federal court on charges of wire fraud.)

Outcome: OCI examiner Nitza Pfaff tells Gordon Physicians Plus "did not violate an insurance law or regulation" so there's nothing more OCI can do. He is advised to complain to the state Department of Workforce Development or initiate an action in small claims court.

Epilogue: Gordon, in an interview with Isthmus, says his bills for this health emergency total about $17,000, which he has not paid; this has hurt his credit and prompted calls from collection agencies. He says other former workers of Platinum Concepts, a mortgage company which at one point had 22 employees, were stuck with bills because of the undisclosed cancellation of their health coverage. He's gotten some back wages through a complaint with the state Department of Workforce Development. As for OCI's involvement, Gordon is unsure what it did: "They sent me a letter saying a few things and that was it."

Verdict: Unsatisfactory.

27. 207316 - N.M. and J.M.

Madison 53719

Complaint received: 6/2/09

File closed: 6/16/09

Complaint against: Physicians Plus Ins. Corp

Official reason/disposition: "Denial Of Claim," "Claim settled"

Problem: J.M. explains, in an enclosed letter to Physicians Plus, that his son N.M. became seriously ill and "could not swallow" after having dinner with his girlfriend. J.M. took the young man to the closest emergency room, at St. Mary's, where he received an adrenalin injection and was given a prescription. Physicians Plus subsequently denied payment because St. Mary's is not a participating provider. J.M. questions this, writing: "I would hope that those of us on the appeals committee that are concerned parents would take your child to the closest available care."

OCI action: Sends Physicians Plus the complaint along with a form letter asking it to reply to the complainant within 10 days and to OCI within 20 days.

Company response: Physicians Plus tells OCI that it has "reviewed denied charges and have decided we would pay those charges at this time," except for a $100 co-pay for ER use.

Outcome: OCI managed care specialist Barbara Belling writes J.M. to say that the complaint has been resolved and to lecture him on his responsibilities: "When you enroll in an HMO plan, you agree to use participating providers for all covered services. Of course, if you need medical attention as soon as possible due to an emergency, you should seek care at the nearest emergency room. However, it is a good idea to become know [sic] which hospitals, urgent care centers, and clinics are participating providers in your area so you can use those providers whenever possible."

Verdict: Satisfactory.

28. 207385 - Joe "Kay" (last name a pseudonym, on request)

Madison 53705

Complaint received: 6/4/09

File closed: 7/28/09

Complaint against: Dean Health Plan Inc.

Official reason/disposition: "Policy Provisions," "Contract provisions"

Problem: Cut hand while out of town on 10/11/08; went to St. Vincent hospital in Green Bay. Got seven stitches. Dean Health Plan policy says ER visits are covered except for $75 co-pay. But Dean paid just $454.25 of a $1,100.70 bill, saying the rest was for "ancillary services." Kay pays the $646.50 bill, but wants a refund for $571.45, minus his $75 deductible. Kay alleges that the "ancillary services," which included the physicians' fee, were for the stitches.

OCI action: Sends Dean the complaint along with a form letter asking it to reply to the complainant within 10 days and to OCI within 20 days.

Company response: Dean upholds the denial, saying the claims were processed correctly, according to policy provisions. It says the amount not covered is for "ancillary and diagnostic services," but does not specify what these are.

OCI action: OCI managed care specialist Barbara Belling writes Kay on 6/29/09 to say it is "unable to resolve your complaint to your satisfaction": "The company is continuing to maintain that it paid the claims for emergency care you received correctly according to the policy purchased by you employer." There is no apparent violation of an insurance law or regulation, and hence nothing more that OCI can do. She suggests Kay may want to "consult an attorney or seek a resolution through Small Claims Court."

Kay response: Writes a follow-up letter to Dean that includes his 7/2/09 letter to Kelly Hagenbuch, the head complaint person at Dean. Disputes he received "ancillary" services: "I went to the emergency room to receive stitches for a wound that required treatment, and thus the treatment (stitches) for the emergency (the wound) was the primary service rendered and was not an 'ancillary' treatment."

Company response: Dean's Hagenbuch, in a 7/23/09 letter to Kay, reasserts that "the claims were processed correctly according to your policy provisions. It quotes this policy language: "Ancillary services are provided in addition to an office visit, urgent care visit or emergency room visit. These services may include, but are not limited to, labs. X-rays or diagnostic tests provided during a physician, emergency or urgent care visit." This list does not include stitches to close a wound and Hagenbuch does not specify what services received by Kay are considered "ancillary."

Outcome: Belling writes Jay to again say there is nothing more that OCI can do. Her letter closes with the standard line: "Thank you for bringing this matter to our attention. Your complaint is helpful to us in monitoring the insurance industry in Wisconsin."

Epilogue: Kay tells Isthmus the company's response struck him as nonsensical, and he's surprised that OCI did not object: "In a perfect world, I would have had someone at OCI look at this who knows insurance, knows the law, knows the market and has the authority to make a determination." Instead, he felt that OCI just wanted to "make me go away."

Verdict: Unsatisfactory.

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