We take Kaiser Permanente to
the Maryland Insurance Administration
Continued from Part 1...
Dr. [name withheld to protect the innocent] informed us that with KP, we would have to go through a few times with unsuccessful IUI in order to qualify for IVF. All the attempts we had made in other countries weren't enough to prove to KP that we were good candidates for IVF. So the games continued, with time passing by.
Although no reproductive abnormalities had been noticed in either myself or my wife by any of the doctors in 4 countries, thanks to KP's delays, time had passed to the point that a hormonal test indicated not only IVF but also a donor egg. Dr. [name]'s insurance liaison called KP and was told that IVF was not covered at all if we use a donor egg. I would have expected that in a total of over 400 pages selling their program, KP would be able to explain any exclusions they may have. No exclusions like this are presented in the literature I had and both KP and the [employer] had informed me that no exclusions like this existed since no other literature pertained to reproductive medicine in our policy.
On January 26th
at 11:22AM I spoke with Katrina at extension 6264. We discussed IVF
and asked why IVF would not be covered with a donor egg when I was
informed that it would be covered. She checked my policy and said
that she didn't know why someone had told Dr. [name]'s office
that it wouldn't be covered. Since KP recorded the conversation, it
will be on record that I mentioned donor egg at least 2 or 3 times.
I requested that KP preserve this quality assurance recording.
At 15:20, I insisted with a customer service representative to speak with a supervisor. Reluctantly, she transferred me to Lena Flemming. Ms. Flemming read from a document which she later faxed to me. On page 8 of this document, (under "Infertility Exclusion(s)") it only excludes the retrieval of donor eggs. Although the wording of the title of this paragraph infers that it is a complete list of exclusions, page 3.10 states that any "procedures...that includes (sic) the use of donor eggs" are excluded.
By law, an insurance representative selling someone an individual medical policy must present the policy provisions before accepting payment for the policy. Why would this not be a legal requirement when one is signing up for a policy?
In these conversations, the KP employees referred to an "Evidence of Coverage" (EOC). I checked with Ms. [name] of the Benefits office and she again ascertained that she had not heard of such a document and KP had given them none, so they obviously had none to give me. (Finally on March 7, four months after beginning payment for the insurance, they provided me with the EOC. At this point, I was locked into this insurance policy because open enrollment wouldn't start for two more months, which is inadequate for us. This bait and switch tactic is unethical at best if not illegal.)
I then requested of Dr. [name] that he perform the IVF with my wife's eggs, KP had yet to present any exclusions from coverage for that. The physician told me that KP would not cover that either, but he promised to write a request to overturn the denial of authorization.
KP replied to that appeal on April 30, 2007. (See enclosure C.) They wrote, "We have overturned our initial denial and approved your request." We were ecstatic and called Dr. [name]. He was also interested in this ruling and called KP. They responded to him that the procedure approved was for IUI, a procedure for which we had approval for 3 months and was inadequate for us. One KP hand clearly didn't know what the other was doing. They approved something that wasn't requested and didn't respond to the request. More time was passing and fertility decreasing.
We appealed again and notified KP that we would take the case to the Insurance Commissioner if they continued denying benefits promised and paid for. On June 6, they responded, "We have thoroughly considered all of the available information related to your request... Your request was denied because your benefits...does (sic) not include coverage for donor egg services." Once again, they didn't address our appeal for permission to get coverage even for using my wife's own eggs. I wrote, "we request that you honor your initial commitment cover at least that portion of IVF that was initially promised."
Additionally, on or about February 22, 2007, I purchased several prescribed medications, using the KP pharmacy as they require. On December 9, the price I had paid for the Follistim 900U at Professional Pharmacy was $682.50 ($2047.50/3), retail with no insurance coverage. (See enclosure D.) The receipt for Follistim 900U from KP says "KP Price $3658.96" (for 4), "You Pay $1829.48". (See enclosure E.) Since I could get the same medication elsewhere for much less than $3659, I asked the pharmacy why the KP price was so high, as I'd much rather pay 50% of $682 per box than 50% of $915. They told me that I must buy from them, that the $1829 is not the 50% left after KP's copayment but that the 50% reimbursement would come from KP in the form of half the $1829 once I submit the paperwork. In March, I submitted all the paperwork they requested, requesting the 50% reimbursement they promised in the policy and orally. I have still not been reimbursed the $1534 of $3068 we paid. I wrote them on 4/27 and 5/29. I telephoned them on 5/29 and complained to Mitchel Alston on about 6/28 and 6/29 and he promised that they were faxing me a response "as we speak". To date, I have not received reimbursement or any response. I have requested an additional 1% monthly interest on their overdue payment.
In conclusion, my accusations of unethical and illegal practice are as follows:
For two months, we paid for insurance yet were not permitted to make claims on it. If it takes 60 days for a company to be ready to assume the risks that they accept when they sign the agreement, forcing the client to pay and making him or her believe they are covered is highly unethical.
KP makes great promises in 400 pages of documents to get a prospective insured to sign on the dotted line. When I requested any further information on the policy I was considering, they clearly told me that no further insurance contracts and plan documents exist, at least as pertain to reproductive services.
They imply once and clearly inform us a second time that donor eggs would be covered. Then when it comes time to benefit from the service, they refer to 40 (or more) pages that should have been provided to an applicant in the packet to provide a true picture of the contract he or she is signing. Although this surely adds to their revenue stream, it is unethical if not illegal.
Their disorganization and delays resulted in my wife's capacity for reproduction to deteriorate to the point that we could no longer benefit from the insurance for which we were paying. When we had finally gone through all the red tape to satisfy KP that we really needed IVF, the opportunity for it to be used effectively had passed. This saved KP thousands of dollars in claims that they knew they might be assuming when I enrolled in their insurance policy. This is not only corrupt practice but also increases the mental trauma on people who want to have children and now cannot as well as increasing the likelihood of breast and ovarian cancer due to a woman's not bearing children.
Until the end, they continued to deny coverage for IVF with my wife's own eggs without giving any explanations or supporting KP's denial of coverage by identifying any written exclusions in the policy materials provided to me when the agreement was entered into with them but instead responded to issues they had answered 3 months before.
They claim to record telephone conversations for quality purposes yet refused to ensure that they were listened to and applied to ensure the quality of service to us.
Although it is too late for my wife and me, please inform me of what you can do to bring justice for the many others being exploited.
Based on this experience, I have requested from my employer that I not be place on any medical insurance program but I was told that this would not be possible. Can you advise me on this as well?
CC: George C. Halvorson,
CEO, Kaiser Permanente, 2101 E. Jefferson St,
Rockville, MD 20852
The Maryland Insurance Administration ruled on September 26, 2008 that "Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. has violated Maryland insurance law" in this case.