Commissioner Senn Adopts Health-Insurance Grievance Rule to Aid Consumers Appealing Denials of Treatment.

OLYMPIA, Wash.--(BUSINESS WIRE)--Dec. 1, 1999--

State Insurance Commissioner Deborah Senn has adopted a new state rule that requires health insurance carriers to quickly review denials of care at consumers' request. The new rule goes into effect on December 30.

"This rule will make sure not only that consumers get a quick, fair review of any denial, but that it is also put on an expedited basis if a doctor decides the treatment is an emergency," Commissioner Senn said.

"It is simply unfair to expect sick people to fight their insurance company and their illness at the same time," Commissioner Senn said.

The new rule applies to the immediate appeal consumers can file when they disagree with their carrier's decision to disapprove care. The rule does not replace other built-in appeals for the consumer.

The rule sets a standard for carriers to review any subscriber's appeal within two weeks. But if the treating doctor ruled the situation an emergency, the company would be required to speed up the review and have it completed within 72 hours.

Under the rule, the reviewer would have to be:

-- Someone not involved in the first denial.

-- Knowledgeable about the condition and with the training,

experience and expertise to render a competent decision.

The rule also:

-- Requires the carrier to cite the actual clinical reason for

the denial.

-- Prevents the carrier from penalizing any doctor who

advocates for his or her patient in the review.

Commissioner Senn noted that the expedited-grievance rule marks a step forward for consumers but that it does not eliminate the need for more substantial reform of the way managed-care systems approve health care.

Commissioner Senn said she still believes managed-care consumers need an external-review guarantee so that patients fighting for life-saving treatment will always have the right to a final appeal beyond the carrier, preferably by access to an independent, third-party review panel of medical experts.

She noted that a Patient's Bill of Rights in the last session of the Legislature included such a guaranteed review. Although the bill stalled in the 1999 legislative session, sponsors have promised to revive the measure and work for it again next year.

EDITORS: Any insurance consumer experiencing difficulties with a carrier or who feels that he or she has been treated unfairly may request an investigation by Commissioner Senn's office. Consumers also can obtain a copy of the new rule on expedited grievance procedures by calling the toll-free Consumer Hot Line (1-800-562-6900) or visiting Commissioner Senn's Internet Web Page at http://www.insurance.wa.gov