The New Hampshire Challenge

Volume 16, Issue 3

Spring 2004

published quarterly by: The New Hampshire Challenge, Inc. P.O. Box 579, Dover, NH 03821-0579


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In This Issue

...has undergone many changes in recent decades. During the last century, Congress delegated insurance regulation to the states. It was a plan that worked well because health care needs and available services were matched locally. You took your family to a local doctor for routine care and to the nearest hospital for specialized care. The cost was covered by your insurance carrier with little or no out-of-pocket expenses for you. The state insurance department made sure that the insurance companies remained solvent and that the price of premiums was fair.

The 1970s saw the beginning of change for health insurance. New medical technologies and treatments emerged, most notably in the areas of heart disease and cancer. Many cancers previously considered fatal now respond to new surgical and drug treatments and other types of intervention (e.g. bone marrow transplant). Blocked heart arteries that formerly caused early death can be surgically replaced. Organ transplantation has become almost a routine procedure. Families now have access to sophisticated treatment at medical centers far from home.

All of these advances in medicine have improved the quality of life for many people but they come at a price. Health insurers, in response to escalating costs, began to restrict benefits, increase co-payment amounts, and raise premiums. Health maintenance organizations (HMO) and employer funded plans gained popularity as cost control mechanisms.

Traditional fully insured plans like HMOs, individual health plans, and group insurance are regulated by the state and subjected to the state mandated benefit requirements. But employer funded/administered plans are overseen by the U.S. Department of Labor and generally have no benefit mandates. According to N.H. Deputy Insurance Commissioner Alex Feldvebel, only 60% of health insurance plans in New Hampshire are fully insured plans. Approximately 40% of plans are employer administered or funded, including the Signa plan for state workers.

When you have a problem with your health carrier, what should you do?

It depends on what kind of health coverage you have. The first thing to do is get a copy of your policy. All health plans are required to provide each beneficiary with a detailed copy of the policy when the plan begins or at any time upon request. The policy will list the covered expenses and, often, what is not covered.

For H.M.O., group, or other fully insured plans, when you or your provider sends a bill to your insurance carrier, the insurer must acknowledge the claim in writing within 10 business days. The insurer must make a decision regarding payment or denial within 30 business days. If your claim is denied and you are not satisfied with the response of the insurer, you can appeal the denial.

You are entitled to two levels of internal appeal. Within 180 days of the denial you can submit an appeal to the insurance company and, if the first appeal is denied, you can file a second.

Your insurance company must make a determination on your appeal according to the following:

Urgent care claim appeals must be resolved as expeditiously as your medical condition requires, but in no event more than 72 hours at each (appeal) level. An urgent care claim is a claim involving a matter that would seriously jeopardize the insured's life or health.
Non-urgent pre-service claim appeals must be resolved within a reasonable time appropriate to your medical circumstances, but in no event more than a total of 30 days.
Post-service claim appeals must be resolved within a reasonable time appropriate to your medical circumstances, but in no event more than a total of 60 days.

Since 2000, New Hampshire law gives consumers the right to an independent external appeal if an insurer denies a second internal appeal or doesn't respond to the appeal within the mandated time frames. You are entitled to an external appeal within 180 days of the internal appeal denial if the service is a covered benefit amounting to at least $400 over 12 months and you have completed the internal appeals process.

An Independent Review Organization (IRO) certified by the state reviews the external appeal requests. The IRO is a network of medical experts who review your appeal. The insurance company pays their fee. The IRO decision is binding on you and the health insurer and enforceable by the Insurance Department. External appeal is not for malpractice claims or for settling other types of professional fault.

To request an independent external review you must submit to the Insurance Department a completed Independent External Appeal form along with a copy of the insurer's letter denying your internal appeal, a copy of your insurance card, a copy of your certificate of coverage listing your benefits, and any relevant medical records or other information you wish the IRO to consider.

Within 7 business days, the Insurance Department will notify you whether your case is eligible for review. If your request is accepted, the Insurance Department will select an IRO and notify you and your insurer. Within ten days of this notice, the insurer must provide all information relevant to the case to the IRO and to you. You have another ten days to submit additional information to the IRO. The IRO has 20 days to review the documents and render a decision.

You also have the option of filing a complaint with the Insurance Department. If you file a complaint, the Insurance Department can serve as mediator in your dispute with the health carrier.

The complaint must include:

Your name, address, phone number;
The name and address of your insurance company;
The policy number and date of issue,
The claim number and date of the service;
A description of your problem with your insurance company;
Details of your attempts to resolve the matter with the insurance company;
Copies of any relevant letters, papers, and written communication;
Finally, your proposal for a fair resolution.

The Insurance Department will forward your complaint to the company, which must respond within 5 weeks. However, Insurance Department complaint mediation is non-binding and the final resolution must be agreed upon by you and your insurer. You can also file a complaint online with the National Association of Insurance Commissioners. Your complaint will be forwarded to the NH Insurance Department. If you work in another state, you must contact that state's insurance department.

If your health plan is employer funded/administered or a union plan, the first step to resolve a dispute is to contact your union or company's human resource office. A good working relationship with your employer is important when resolving a health care dispute. Kathy Belanger of New Hampshire Department of Insurance consumer services recommends you "first go to your employer and appeal on a personal level because there is no legal mandate requiring an employer to cover health care and the employer has full control."

If you cannot reach a desirable resolution with your employer, you can contact the U.S. Department of Labor, which has jurisdiction over employee benefits. Before filing a complaint with the Department of Labor, you must write a letter of appeal to your plan administrator listed on your policy. You have 60 days to appeal a denial and the administrator must respond to your appeal within 60 days of receiving your letter of appeal.

Government and church employee plan disputes are resolved by the governing body of the employer because they are not regulated by either the New Hampshire Insurance Department or the U.S. Department of Labor and. In some circumstances, the Americans with Disabilities Act provides protection for those with self-funded health coverage.

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