Consumers won reversals for 47% of health claim denials in New York


Consumers in New York won nearly half of the internal appeals they filed against health insurers in 2009, according to the New York State Insurance Department.

Its new Consumer Guide to Health Insurers indicates that of the 71,787 cases where people were seeking to reverse a health insurer’s denial of coverage, exactly 33,921 won their appeals.

In cases involving HMOs, consumers won 2,332 reversals in the 5,968 cases closed by the state last year. In cases involving nonprofit health insurers, appellants won 4,329 of the 8,946 appeals closed last year.

In the case of the external review process, where appeals are decided by independent third-party health care professionals, there were 812 appeals of commercial insurers’ denials of coverage. Consumers won reversals, in whole or in part, 341 times. There were 570 external appeals against HMOs with consumers winning reversals or partial reversals 219 times. There were 395 appeals against non-profits with consumers winning reversals in whole or in part 162 times.

In the guide’s comparison of HMOs, the average score was 63, with CDPHP scoring highest (74) and Atlantis Health Plan scored the lowest rating (38).

CDPHP, HealthNow New York and MVP all tied for the highest score when HMO members reported receiving care quickly. CDPHP scored highest among HMOs in terms of consumer satisfaction with provider communication and breast cancer screening, according to the guide.

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