State fields few health insurance complaints

Although nearly 2 million Oregonians were covered under private health insurance policies in 2015, state regulators fielded only 1,120 complaints about the policies that year.

One possible explanation is that few are aware the state’s Department of Consumer Business Services has consumer advocates who take up such disputes free of charge. Undoubtedly, the vast majority of insurance complaints are resolved directly with carriers. Most that reach state regulators do so only after carriers and their clients were unable to reach resolution.

DCBS spokesman Jake Sunderland said it’s important that people know they have someone who’s on their side.

“The insurance company’s word doesn’t always have to be the last word,” he said. “So if you have any concerns, if you feel like you’re not getting a fair deal or if you just want to understand your insurance better, please don’t hesitate at all to call us. We have a team here to help you and they really want to talk to you.”

Oregonians paid a collective $6.3 billion in premiums for private health insurance policies in 2015. Of the complaints that went to state regulators, 320 were found to represent actual violations of policies or the law, according to DCBS data.

Nationwide, the most common reason people filed complaints with state insurance regulators last year was delays in getting their claims processed, according to the National Association of Insurance Commissioners, which sets standards and provides support for insurance regulators. Not far behind was claim denials, followed by an unsatisfactory settlement or offer from the carrier.

Oregon’s data doesn’t include complaints carriers were able to resolve in-house.

It’s possible the small number of complaints that come to state regulators might be because people aren’t aware there is an agency that will take up their disputes. For his part, Sunderland said it’s hard to say whether that’s the case.

“I think the important thing is that stories like this get the word out about it,” he said.

Lori Long, a spokeswoman for Health Net, said it’s bigger than that. She pointed out that state and federal law also require carriers to perform an in-depth internal review process when complaints come in. Customers are permitted to file an appeal, then a grievance and, finally, request an external review, she said.

“I think the numbers are low because the consumer has so many options,” Long said.

Eighty-one Health Net Health Plan of Oregon customers brought their complaints to state regulators in 2015. Of those, 32 were confirmed. Health Net made nearly $187 million in premiums.

DCBS fielded 117 complaints from Kaiser Foundation Health Plan of the Northwest customers. Of those, 54 were found to be legitimate, according to the data. Kaiser took in $1.8 billion in premiums that year, more than any other private carrier.

Kaiser spokesman Michael Foley wrote in an email that the complaints the state receives are submitted directly by the public and that verified complaints are forwarded to the company for review. Providence Health Plan customers, who paid nearly $673 million in premiums in 2015, submitted 80 complaints to state regulators that year. Of those 15 were verified.

Gary Walker, a spokesman for Providence, wrote in an email that the company manages complaints with the utmost importance.

“We are proud of our performance and continue to meet the highest quality and service levels attainable in the industry,” he said.

Aetna’s customers paid nearly $85 million in premiums in 2015. They filed eight complaints, two of which were found to be legitimate.

Walt Cherniak, an Aetna spokesman, wrote in an email that the company takes all complaints seriously.

“Aetna has dedicated teams responsible for reviewing and responding to complaints and grievances,” he said.

Patrick O’Keefe, the owner of Cascade Insurance Center in Bend, said most of the time he hears about complaints, it’s because somebody doesn’t fully understand their policy.

“People have this impression with health insurance companies, ‘They’re always just trying to deny the claim first,’” he said. “I have just found that to not be the case.”

When someone files a complaint, they have to provide specifics about their situation and policy. After that, their complaint is paired with a member of the agency’s consumer advocacy team who reviews the complaint, the insurance policy and relevant state and federal laws to determine whether a violation took place. The agency then acknowledges the complaint with a letter to the person who filed it. A letter also goes to the insurance carrier to get their side of the story.

The consumer advocate then reviews the carrier’s response, the original complaint, asks follow-up questions and makes a determination about whether there was a violation of the law or policy, Sunderland said. The process typically takes 60 days, although some disputes are resolved much faster and some take more time.

“What we do is we do our best to make sure that you are getting the benefits that you are entitled to under the terms of your policy and the law,” Sunderland said.

Potential outcomes could include having the carrier pay for the service they had originally denied or refund premiums, copays or coinsurance.

It’s a difficult process to summarize, since every situation is so different and complex, especially when it comes to health insurance, Sunderland said.

“Please don’t ever hesitate to reach out to us,” he said. “This is what we do. Our team is very passionate. We want to help Oregonians when they have any questions or issues about their insurance.”

The agency recently posted the 2015 complaint data, which spans all lines of insurance, to its website as PDF documents. The information is coming well after 2015 because the agency’s IT staff was trying to build a user-friendly searchable database, which ultimately didn’t pan out.

“They kept telling us it would be ready in a month, it would be ready in a month,” he said. “Eventually, there were just so many problems that we decided to go ahead and publish the hard copy PDF list instead just so that we would get that data out there.”

Sunderland added, complaint data for 2016 will likely be made publicly available midyear.

— Reporter: 541-383-0304,

tbannow@bendbulletin.com

Filing a complaint

To file a complaint with the Department of Consumer and Business Services, call 888-877-4894. That’s a toll free number that calls the office in Salem. You can also file a complaint online at: http://dfr.oregon.gov/gethelp/Pages/file-a-complaint.aspx.