JustHealth

JustHealth's Legislative and Regulatory Project - JustHealth suggests and supports legislation and regulations that protect the rights of consumers and providers from dangerous, deceptive, dishonest, unfair or unlawful acts and practices - and move us in the direction of a just healthcare system. Examples of our Legislative and Regulatory Project are included.

Regulations:

Some Regulations For Which JustHealth Provided Substantial Input

3. Fair Claims Settlement Practices Regulations - Title 10 of the California Code of Regulations, Sections 2695.1-17

Cal. Admin. Code tit. 10, s 2695.1

BARCLAYS OFFICIAL CALIFORNIA CODE OF REGULATIONS

TITLE 10. INVESTMENT

CHAPTER 5. INSURANCE COMMISSIONER

SUBCHAPTER 7.5. UNFAIR OR DECEPTIVE ACTS OR PRACTICES IN THE BUSINESS OF INSURANCE

ARTICLE 1. FAIR CLAIMS SETTLEMENT PRACTICES REGULATIONS

This database is current through 07/14/06, Register 2006, No. 28..

s 2695.1. Preamble.

(a) Section 790.03(h) of the California Insurance Code enumerates sixteen claims settlement practices that, when either knowingly committed on a single occasion, or performed with such frequency as to indicate a general business practice, are considered to be unfair claims settlement practices and are, thus, prohibited by this section of the California Insurance Code. The Insurance Commissioner has promulgated these regulations in order to accomplish the following objectives:

(1) To delineate certain minimum standards for the settlement of claims which, when violated knowingly on a single occasion or performed with such frequency as to indicate a general business practice shall constitute an unfair claims settlement practice within the meaning of Insurance Code Section 790.03(h);

(2) To promote the good faith, prompt, efficient and equitable settlement of claims on a cost effective basis;

(3) To discourage and monitor the presentation to insurers of false or fraudulent claims; and,

(4) To encourage the prompt and thorough investigation of suspected fraudulent claims and ensure the prompt and comprehensive reporting of suspected fraudulent claims as required by Insurance Code Section 1872.4.

(b) These regulations are not meant to provide the exclusive definition of all unfair claims settlement practices. Other methods, act(s), or practices not specifically delineated in this set of regulations may also be unfair claims settlement practices and subject to California Insurance Code Section 790.03(h) and/or California Insurance Code Section 790.06. These regulations are applicable to the handling or settlement of all claims subject to Article 6.5 of Division 1, Part 2, Chapter 1 of the California Insurance Code, commencing with Section 790, except as specifically provided below:

3. Broker Fee Regulations - Title 10 of the California Code of Regulations, Sections 2189.1 - 2189.8

The Department's new broker fee regulations can be found in Title 10 of the California Code of Regulations, Sections 2189.1 - 2189.8. The new regulations will help protect insurance consumers from virtually all of the most common unfair broker fee practices. In addition, the regulations provide written guidance to insurance brokers concerning broker fees for the first time since the Department issued Bulletin 80-6 in 1980.

JustHealth brought many of the deceptive broker fee practices to the attention of the Department in 1999 and 2000, and worked with the Department to try to develop pamphlets that would inform consumers of these practices.

The fact and ill-effects of these practices became an international focus of attention after New York Attorney General, Elliot Spitzer, filed suit against Marsh & McLennan Companies, the country's largest insurance broker, in October 2004.

3. Disability / Health Insurance Policy Language - In the Matter of Withdrawal of Policy Form Approval - Discretionary Clauses

The California Insurance Commissioner withdrew approval of discretionary clauses (which are used to make the promised insurance nothing more than a costly and destructive illusion) in policies of disability insurance issued by UnumProvident, Hartford and their subsidiaries. The insurers expended, and continue to expend, substantial resources opposing and resisting the Commissioner's actions. JustHealth intervened to support the Commissioner. Thus far, the Commissioner has prevailed and these provisions are banned.

John Metz and JustHealth had brought many of the issues regarding misconduct by disability insurers, including UnumProvident to CDoI's attention in the late 1990s. John Metz and JustHealth provided substantial input to CDoI, regarding UnumProvident's wrongful conduct, which assisted CDoI in performing its regulatory duties towards this entire segment of the insurance industry.

The Commissioner noted that many of the provisions of this agreement will eventually apply to all other disability insurers operating in the California market. "Today's action goes beyond UnumProvident," he said. "California's disability insurers now have a new standard, one that will provide a better sense of security for policyholders, which is what disability insurance is really all about."

5. 2001 > Proposed "Under Oath" Regulations

As a result of our observations while assisting consumers and providers with their problems with the current health care system, it became apparent that many decisions are being made by regulators to the detriment of consumers and providers, in reliance on information provided by HMOs, health insurers and their associates, that contains misleading or false material information or that omits material facts.

In and after 2001, JustHealth proposed the following rule be adopted by the DoI, A similar rule was proposed for adoption by the DMHC. As of now, both have refused to adopt them.

If a Licensee wishes the Department of Insurance to rely on any document or other information submitted by the Licensee, or by any person in support of the Licensee's position, in connection with any determination related to any rate making, rule making or complaint filed by any person against a Licensee, a person with firsthand knowledge of the material facts contained therein shall certify under penalty of perjury that the document or other information: 1) does not include any statement containing false or misleading information about any fact that is material to the rate making determination or complaint; and 2) does not conceal or fail to disclose the occurrence of any event that affects the rate making or rule making determination or the initial or continued right to any insurance benefit or payment, or the amount of any benefit or payment to which any person is entitled.

The Department of Insurance shall not rely on any document or other information in making any such determination, unless it complies with the foregoing requirements.

6. 2004 - Broker Fiduciary Duties - RH04039144 - California Code of Regulations, Title 10, Chapter 5, Subchapter 1, Article 5.9, Section 2184.1-3

These regulations were proposed to deal with a systemic problem in the insurance industry that became widely recognized after New York Attorney General, Elliot Spitzer, filed suit against Marsh & McLennan Companies, the country's largest insurance broker. JustHealth brought many of these practices to the attention of the Department in 1999 and 2000. We worked with the Department to craft regulations that would limit the harm caused by the current deceptive practices. They have yet to be enacted. We also worked with the Legislature to prevent the passage of legislation that would have exacerbated these problems.

Legislation and Ballot Measures:

Some Legislation and Ballot Measures For Which

JustHealth Provided Substantial Input

1. 1996 - We drafted document from which the core elements of both Prop 214 and 216 were taken.

2. 1997 - We responded to a request from the Office of the Public Advocate of the City of New York and provided input on legislation to protect New York consumers from dangerous, deceptive, dishonest or unfair practices in their health care system.

3. 1998 - HMO Health Insurer Honesty and Accountability Act

HMO Accountability Act

Summary

1. When an HMO or health insurer ("HMO") commits an unfair, deceptive, dishonest or fraudulent act it must be held accountable, just as any Consumer, Provider or any other person would be.

2. HMOs cannot be allowed to control decisions directly or indirectly and then escape responsibility for the consequences of the decisions. <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 3.2//EN">

3. A Consumer's health care records and private information cannot be sold or disclosed by an HMO to anyone without the consent of the person.

4. Health care providers cannot be "gagged" and prevented from telling people what treatment options are available or that an HMO is breaking the law.

5. HMOs must pay for covered services promptly.

6. Providers will not be punished for providing a covered health care service.

7. Providers will not be rewarded for denying a covered health care service.

8. When a business functions like an insurance company it must be held accountable like an insurance company.

9. Health insurance is not a guessing game. You will be told what you are buying in plain, easily understood language - and get what you were promised.

10. HMO clerks will no longer be able to make medical decisions. Denials of benefits will only be made by properly qualified providers.

11. You will be told every reason why any benefit is being denied, so you will have a fair chance to dispute it, if you think the HMO is wrong.

12. If you disagree with your HMO's decision, you will have a fair chance to prevail.

13. You will not be forced to give up your rights by an HMO or anyone.

14. Some HMOs engage in the same unfair, deceptive, dishonest or fraudulent practices over and over again because their victims are compelled to keep silent about what was done to them as the price for getting paid what they were owed to begin with - or even much less. The next victim never knows that it has been done before. This practice harms us all and must cease.

15. No one should fear that by standing up for their rights or those of their friends, families, patients, co-workers or anyone else they will be harmed by an HMO or anyone.

16. For these rights to be meaningful, people must be able to effectively enforce them directly without relying entirely on the government.

 
3. 2000-2001 - Health Care Options Project ("HCOP ") - JustHealth (CCHCC) was the fiscal agent for the California Endowment's Grant to HCA-CA for the work done on the HCOP.

4. 2000-2003 - Department of Managed Health Care Intervenor Rules - Health & Safety Code section 1348.9. - In or about 2000, at the very beginning of DMHC's existence, JH suggested to DMHC that it implement a program to permit compensation for qualified intervenors modeled on the existing program at the Department of Insurance. These suggestions were initially rejected out of hand. They were adopted and became effective on January 1, 2003. They will be repealed unless reauthorized by January 1, 2007.

5. 2001 - Kennedy McCain Edwards - Patients Bill of Rights

6. 2002 - As a result of observations made regarding what people who came to us for assistance were often forced to endure when their situations required assistance from attorneys and/or engaging in litigation, we proposed amendments to California Civil Code Section 47 (see attached document).

7. 2002 - Provided input to Sen. Kuehl's CalCare legislation re:

Structure, Functions, Powers of Cal Care Consumer Advocacy Entity,

Qualifications of and Restrictions Imposed Upon the Consumer Advocates

And Those Who May Influence Them

8. 2002 - Provided input to Colorado legislators who were considering a bill which would place restrictions on auto insurance managed care companies.

9. 2005 - As a result of observations made regarding what people who came to us for assistance had to go through to obtain access to their own test results, we proposed legislation to Assemblymember Fran Pavley to allow patients to access their test results directly from the lab without having to get approval from the physician, in addition to the physician receiving the information.

10. 2005 > Supported Federal legislation to protect the privacy of patients' confidential medical information, by passing a Ethics Based Medical Privacy Act or having patients granted the right of prior informed consent in various pieces of legislation that are currently wending their way through Congress.

11 2005 > SB 840 Kuehl - California Health Insurance Act

12. 2006 - AB 774 Chan - Hospital Overcharging

August 24, 1999:  http://www.sfgate.com/cgi-bin/article.cgi?file=/chronicle/archive/1999/08/24/MN31615.DTL