Ask the Insurance Warrior
6/9/07

Q: Should I call the Insurance Commissioner?

A: Short answer ... maybe. The title of today's answer ... Insurance Commissioner: Friend or Foe?

Each of you has your very own Insurance Commissioner ... or, should I say, an Insurance Commissioner for your state. His job is to oversee the insurance business in your state. As you can imagine, the scope of an Insurance Commissioner's activities varies widely from state to state, as does the extent of his/her aggressiveness.

Many who are fighting denials of care do not know about the Insurance Commissioner, don't bother with the Insurance Commissioner, or do not know how the Insurance Commissioner could help them.

Before you can enlist the assistance of your Insurance Commissioner, you have to determine ...

Which Commissioner am I looking for? If you live in California, and the office of your insurer is in Arizona, contact the Insurance Commissioner of Arizona. It's where your insurance company lives, not where YOU live.

How do I find the Insurance Commissioner for my case? There is a wondrous website called www.naic.org. This is the National Association of Insurance Commissioners. Simply pull up the website, and click on "NAIC States and Jurisdictions." You will see a map of the fifty states. Click on your state, and you will be sent directly to your very own Insurance Commissioner. However, before you leave the NAIC homepage, I would suggest having a read of the articles residing there. These people know their insurance. I have refined my approach considerably by reading articles on Insurance Commissioner websites.

How can I get the most out of the Insurance Commissioner's office? First, know that you are speaking to a bureaucracy ... a government bureaucracy. If you explain your urgent appeal situation, your surgery is scheduled for next week, and the person at the Insurance Commissioner's office says, "You need to file a complaint" ... well, you are not talking to the right person. If the person you are talking to has nothing to offer, knows nothing, suggests that you file a complaint ... ESCALATE, just as you would with any other bureaucracy.

What can the Insurance Commissioner do for me? I will tell you what Insurance Commissioners office HAVE done for people who were fighting denials of care.

o When patients were stonewalled by health insurers ("We don't know who to send your letter to," "We don't know who we report to," etc.), I.C.s have been able to give us the names of decision-makers at the insurance company. When we have urgent appeals in process, this giving of names can be a tremendous help.

o I called the I.C. when my health insurer tried to bar my friend from attending a hearing with me. They were able to supply the number of the Washington Administrative Code which stated that the insurer had to cooperate with whomever I chose as my representative. I quoted this code to them, and they let her in. Insurance Commssioners should be very familiar with state codes and regulations regarding health insurance. Call them with questions of "Can they do that?"

o We have heard of I.C.s directly intervening in urgent appeals which have been delayed up until surgery day. In one case, the I.C. called the Medical Director of the insurance company and said, "I will stay on the phone with you all night if I have to, until you make a determination." It wasn't long before that lifesaving surgery was approved.

As all know who read my newsletter in May about "self-funded plans," you know that you needn't bother to call the Insurance Commissioner if you are part of a self-funded plan. If you have a self-funded plan, your insurance is not considered to be insurance, under the law. It is considered to be an "employee benefit." Your employer has final decision-making authority over what medical treatment you get, and your only governmental help will be the federal government -- the Department of Labor.

As I said in that newsletter ... if you have the choice between a funky little HMO and a self-funded plan ... run, run for the HMO.

Get to know your Insurance Commissioner and his website. They may be of great help to you