You Have a Right to Know Why a Health Insurer Denied Your Claim. Some Insurers Still Won’t Tell You.

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by Maya Miller, with additional reporting by Ash Ngu

This story was originally published by ProPublica. ProPublica is a Pulitzer Prize-winning investigative newsroom. Sign up for The Big Story newsletter to receive stories like this one in your inbox.

Series: Uncovered: How the Insurance Industry Denies Coverage to Patients

Health insurers reject millions of claims for treatment every year in America. Corporate insiders, recordings and internal emails expose the system and its harm.

Just outside public view, the American health insurance industry’s algorithms, employees and executives process tens of millions of claims for people seeking medical care.

Sometimes, as ProPublica has reported, insurers base decisions on what’s good for the company’s bottom line rather than what’s good for the patient’s health. Sometimes, insurers make mistakes. In one case we learned about, a company denied a child’s treatment because it based its judgment on adult guidelines instead of pediatric ones. In another, an internal reviewer misread what type of surgery the patient sought and denied coverage based on that error.

At first, these patients had no idea why they were denied treatment. But in each instance, insurance employees left a paper trail — in notes, emails or recordings of phone calls — explaining what happened. Patients and advocates used what they found in those records to craft appeals and ultimately receive the care they needed.

Federal law and regulations require insurers to hand over exactly this sort of information in response to a written request. And they have to do it fast: Most people who get insurance through an employer should get the records, called claim files, within 30 days.

There’s just one catch: Some insurers aren’t turning files over like they’re supposed to. We followed ProPublica readers through the process with five different insurers. Several companies only shared documents with patients after we reached out.

Our team discovered how useful claim files can be after a patient shared internal notes and calculations that a health insurer had made about his case. But few health insurers advertise this service or offer clear instructions for getting these records. To help fill that gap, we published a guide explaining how to submit a claim file request. We also shared resources with health care providers and patient advocates nationwide, including request letter templates.

More than 120 people have told us that they have since requested or intend to request their claim files. Though a handful say they received information that helped them understand why their health insurer denied coverage, many more have been running into challenges. They’ve told us about insurers blowing past deadlines, wrongly requiring subpoenas and — in several cases — misinterpreting their request entirely.

We shared a summary of these examples with Tim Hauser, a deputy assistant secretary with the Department of Labor. His office oversees claim file laws that cover more than 131 million people. He said insurers who fail to provide records are breaking the law. “The claimant really needs to be able to see what the relevant evidence is so that they can respond to it,” he said.

We brought our findings to five insurance companies. We presented them with details about the requests patients had made and how the company had responded, and we asked for an explanation of what happened in each case.

All of the insurers acknowledged that the patients were entitled to the material they’d asked for. Four began sending the files after our inquiry. Two, spokespeople told us, are updating policies to handle future requests. Anthem Blue Cross Blue Shield spokesperson Michael Bowman said the company needed to better train staff on the rules “to close any gaps to prevent this from occurring in the future.” Cigna spokesperson Justine Sessions admitted that patients do not need a subpoena to access their records, contrary to what the insurer had told a member. She said the company would update its “policies and communications to reflect that for future requests. We regret that we did not make these updates sooner and apologize for any frustration or confusion this has caused our customers.”

By crowdsourcing people’s experiences, we identified some patterns in health insurers’ behavior. Here are some of the most common issues people encountered — and what to watch out for if you submit your own request:

Insurers Asking for Unnecessary Subpoenas or Court Orders

Cigna and Anthem told members that they would need to obtain a court order or subpoena to access their claim file records.

“This is completely unheard of,” said Wells Wilkinson, a senior attorney with the nonprofit legal group Public Health Advocates who regularly files these requests. “It also sounds completely illegal. The consumer has the right to any information used by the health plan in the context of the denial.”

On July 12, Lisa Kays, a Maryland resident, asked Cigna for phone call records related to its decision to deny coverage for her 4-year-old son’s speech therapy. “We couldn’t afford to just give up,” Kays said.

In September, Cigna sent her a letter saying she would need to submit a subpoena to get any transcripts or recordings.

After ProPublica inquired, the company sent Kays partial transcripts of the calls. It also reimbursed her for some of the previously denied coverage. She is still waiting for the recordings.

We asked Anthem about a similar case. On July 19, a call center agent told Pamela Tsigdinos she would need a subpoena to receive her claim file records. Tsigdinos had submitted the request 50 days earlier.

Bowman, the Anthem spokesperson, told us the response was an error and apologized. The company compiled the claim file and sent it to Tsigdinos.

Insurers Confusing Claim File Requests With Appeals

At least five people told ProPublica that, after submitting a request for a claim file, their health insurer mistook the request for an appeal.

We brought three cases to UnitedHealthcare. S.J. Farris requested her claim file from the company on May 10. Five days later, she received a response stating that her request for an appeal had been received. Farris sent a clarifying letter but was met with a call from an appeals agent based in Ireland. “I asked her to send the claim files,” Farris said. “She had no idea what I was talking about.”

After ProPublica sent the company questions, Farris received a call from UnitedHealth in October. They told her that the insurer was working on her claim file and that she should expect it soon. In a statement to ProPublica, UnitedHealth spokesperson Maria Gordon Shydlo said: “We take our responsibility to provide members access to their records seriously and have processes in place to comply with the law. We are sorry for any inconvenience.”

After Beth Tolley sent Anthem a claim file request on behalf of her granddaughter, she received a letter from the health insurer stating, “We’ve received a request from Beth Tolley for an appeal.” This left Tolley confused since, in its last communication, Anthem had said all avenues of appeal with its office had been exhausted.

In early October, Anthem sent the Tolley family a check for the amount it had initially declined to cover. Bowman told ProPublica that the company would be sending the records soon.

Insurers Blowing Past the 30-Day Deadline

For most people who get insurance through their employers, insurers are required to send claim files back within 30 days, according to federal law.

Twelve of the people whose requests ProPublica followed did not receive their records within that time frame even though they had these types of plans. Five of those had been waiting for responses from their insurers for more than 70 days before ProPublica contacted the companies with questions.

Isabella Gonzalez submitted a claim file request via certified mail on Aug. 8. When she called Aetna to get an update, a representative told her they did not see it in the system and advised her to upload it onto the insurer’s online portal, which she did. She called back a few days later. A different customer service employee told her Aetna would respond in 45 days.

Alex Kepnes, the executive director of communications for Aetna, said the company at first did not recognize what Gonzalez was asking for and therefore did not respond to it.

Kepnes declined to respond to follow-up questions about why staff failed to correctly identify the request and whether the company would be taking action to ensure this does not happen again.

Other companies that failed to follow the 30-day timeline include UnitedHealth, Anthem and Cigna.

“It’s really important that these responses be timely,” said Hauser, the Department of Labor official. “If that’s not happening, it’s really contrary to the regulation.”

Image: DC Studio/Freepik