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Health plan fined for denying claims

By Kyung M. Song
Seattle Times staff reporter
Kaiser Foundation Health Plan has been fined $65,000 for denying claims from 299 policyholders in Southwest Washington who received care in emergency rooms during 2003 and 2004.

Insurance Commissioner Mike Kriedler announced Friday that Kaiser violated a state law that requires insurers to cover emergency treatments if a prudent layperson would reasonably believe that an emergency exists.

The fine was sparked by a complaint from a female patient whose claim was denied by the insurer. The state then asked Kaiser to review other rejected claims. That internal audit turned up 229 cases in which claims had been illegally denied by a Kaiser physician reviewer, said Beth Berendt, deputy commissioner for rates and forms.

"We found out that the Kaiser doctor was imposing his medical judgment on the claim as opposed to the prudent layperson judgment," Berendt said.

For instance, a person would still be covered if he went to the emergency room with chest pains but it turned out to be indigestion.

Kaiser has paid all the disputed claims and has changed its claims-review procedures to avoid rejecting qualified claims for emergency services, said Gail Mathabane, a Kaiser spokeswoman.

Kaiser, a nonprofit, has about 122,000 members in Washington, mostly in the Longview, Vancouver and Kelso areas. The health plan is part of Kaiser Permanente of Oakland, Calif., the nation's largest health-maintenance organization.

Kyung Song: 206-464-2423 or
Copyright 2006 The Seattle Times Company





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