Consumer Guide to Health Insurance

Finding information about insurers

Cost is just one factor to consider when reviewing policies to purchase insurance. It's also important to look at the insurance company' s financial condition and how the company treats its policyholders.

A health-insurance company's financial information is available from the following rating organizations, which may charge a fee for these services:

AM Best Company
(908) 439-2200
www.ambest.com


Fitch, Inc.
(800) 853-4824
www.fitchratings.com


Moody's Investor Services
(212) 553-0377
www.moodys.com


Standard & Poor's
(212) 438-2400
www.standardandpoors.com


Weiss Ratings, Inc.
(800) 289-9222
www.weissratings.com

One source of information about how companies treat their policyholders is the Consumer Guide to Oregon Insurance Complaints, which ranks insurers from best to worst based on the number of consumer complaints to the Oregon Insurance Division each year. To request a copy, call (503) 947-7984 or (888) 877-4894 (toll-free in Oregon).

Patient-protection reports tell what kinds of complaints health insurers received from enrollees and how the insurer responded with those complaints.

Another method of finding out how insurers treat their policyholders is to discuss health insurance with friends and family. Ask them if they have filed claims and if they were happy with the way their insurer handled their claims. Be sure to get the correct name of the insurance company, as many insurance companies have similar-sounding names.

Settling your insurance claims

Your insurance company must acknowledge or pay claims within 30 calendar days. An extension is allowed if a notice is sent from the insurer to you stating the reason for the delay and telling you what information is being sought. Updates must be givent every 45 days until the review is complete.

Insurance companies must comply with the Unfair Claims Settlement Act, which prohibits an insurance company from the following:

• Misrepresenting facts or policy provisions in settling claims.
  
  
• Failing to acknowledge or act promptly with claims communications.
  
  
• Failing to adopt and implement reasonable standards for a prompt investigation.
  
  
• Refusing to pay claims without a reasonable investigation of available information.
  
  
• Failing to affirm or deny coverage of claims within a reasonable time.
  
  
• Not attempting, in good faith, to promptly and equitably settle claims.
  
  
• Attempting to settle claims at a lower benefit than what a reasonable person would believe they were entitled to based on written or printed advertising material.
  
  
• Attempting to settle a claim on the basis of an altered application without notifying and obtaining your consent.
  
  
• Delaying investigation or payment of claims by requiring duplicate information.
  
  
• Failing to inform you under which benefit a claim was paid, if you ask.
  
  
• Failing to settle claims under one coverage of the policy in order to pay claims under a different benefit of the policy.
  
  
• Failing to promptly provide the proper explanation for denying a claim.

Patient-protection reports

Health insurance companies licensed in Oregon are required to file annual reports with the Oregon Insurance Division. These reports are public information and are available from your insurance company and on the division's Web site. The following reports are available:

Complaint and grievance reports

Each year, your insurance company must report the number of complaints and grievances it has processed in the following categories:

• Access
  
  
• Referral issues
  
  
• Medical necessity
  
  
• Eligibility
  
  
• Other coverage/not covered
  
  
• Quality of care
  
  
• Quality of plan services
  
  
• Emergency services
  
  
• Administrative issues

Utilization-review reports

Utilization review is a set of formal procedures your insurance company might use to determine which medical procedures to cover. Utilization-review is used to save the company money and to monitor medical care. If your insurance company uses utilization-review, it must report how utilization-review decisions are made.

You have the right to receive information pertaining to utilization-review procedures for specific conditions or diseases. Some information might be considered proprietary or confidential and will be shared only orally.

All medical-necessity decisions and decisions about appropriateness of service must be made by a licensed medical doctor or a doctor of osteopathic medicine. You have the right to request a timely external review of denials for medically necessary or experimental procedures.

Quality assessment reports

Quality-assessment reports describe the company's efforts to identify and address customer concerns about quality of care and service. Each year, the company must report how it identifies quality-improvement goals for the health-care services delivered through its providers and the providers' progress toward these goals. This report is required of managed-care organizations only.

Adequacy of provider network

Your managed-care company reports to the Oregon Insurance Division how it monitors its contracted providers to ensure reasonable access to services in the following areas:

• Number of providers, including specialists, in relation to enrollees.
  
  
• Time frames for access to services.
  
  
• Continuity of care when services are disrupted.
  
  
• Access to services for those with special needs.
  
  
• Identification and resolution of access problems.
  
  
• Communication with enrollees and providers.
  
  
• Network evaluation.
  
  

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