Settlement reached over improper denial of emergency medical services claims‏

By Nick Rees | Dec 11, 2009

Tom Corbett (R)

HARRISBURG, Pa. (Legal Newsline) - More than 600 Pennsylvania consumers whose claims for emergency room treatment were improperly rejected by a Harrisburg-based health insurance company will see their claims reprocessed and bills paid as part of a settlement With Attorney General Tom Corbett's office.

HealthAmerica Pennsylvania Inc. and HealthAsurrance Pennsylvania Inc. agreed to an assurance of voluntary compliance following allegations that they used standards higher than the outlined guidelines in their insurance plans for rejecting emergency room treatment claims.

HealthAmerica's plans include a "prudent layperson" standard, which holds that claims will be paid when a reasonable person experiencing symptoms seeks emergency medical care.

"These consumers went to emergency rooms because they believed they needed immediate care for serious medical conditions - something that is supposed to be covered under the HealthAmerica plans," Corbett said. "Using higher standards to reject these claims allegedly left hundreds of Pennsylvania consumers facing thousands of dollars in medical bills that should have been paid by their insurance."

A review of emergency room claims submitted to HealthAmerica from 2001 through 2007 revealed 631 Pennsylvania consumers who appeared to have been improperly denied. Those claims, as part of the settlement, will be reprocessed. HealthAmerica will pay $445,981 worth of claims to address bills for medically treatment that was rejected initially.

HealthAmerica is also required to make changes to its claims review procedures that will ensure adequate information is obtained and proper standards are used in determining if claims for emergency medical services will be approved or rejected.

The settlement also requires HealthAmerica to pay $10,000 in civil penalties as well a $50,025 to cover the cost of the investigation, attorney fees, court costs and future public protection and consumer education activities by Corbett's office.

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