Consumer protection on the line

The patient was all set for surgery. The insurance company had approved the surgery and the patient was in the hospital's administrative office to settle last-minute details. Two days before the surgery was scheduled, the hospital received a notice from the insurance company that the claim was denied. The patient, panicked, contacted the insurance company and was told, "Well, you can always pay cash."

This story was told in several reports I heard on NPR. At least one version was recounted by the patient herself, which reassures me that it is authentic. The implication was that this could be a deliberate technique by an insurance company to confuse patients at the time of the greatest possible tension so they would drop their demand to have coverage for surgery.

Stories of frustration with the health insurance industry are pouring out, following the murder of the CEO of United Healthcare, allegedly by a young man frustrated with that industry. This incident has clearly hit a nerve in the public consciousness.

From the story on NPR, two questions came to mind. First, if this happened to you, what could you do? Second, if an insurance company was making a practice of denying claims, as the NPR report implies, is there a government agency that would detect the pattern and be in a position to intervene on behalf of all the affected patients?

On the first question, your resource should be your doctor and the institution your doctor is part of. If the denial is based on lack of complete information, the doctor can answer questions to justify the claim. This is what several doctors told me.

But if that doesn't work and you don't get your denial reversed, the concern is different.It's not just about you.It's about whether insurance companies are meeting their responsibilities to consumers.

New Mexico has a state agency equipped to address that issue. The agency is OSI, the Office of the Superintendent of Insurance, which licenses and regulates insurance companies. OSI is set up to receive insurance-related consumer complaints and might be able to help resolve your problem. And because OSI might receive multiple complaints on a single issue or from clients of a particular insurance company, OSI can observe if a company has a pattern of denying claims unreasonably or otherwise taking advantage of its clients, and do something about it.

Depending on the specifics, OSI can act on its own, or it might refer an issue to the Attorney General. As just one example, last summer OSI issued emergency orders to help victims of the fires in the Ruidoso area.

Our state government recognizes that a dispute between an individual consumer and an insurance company is not a fair fight, and that's why government has the power to step in and even the odds.

But most vital consumer protections are housed in federal agencies, so I am watching the incoming administration with some wariness.

Under the outgoing Biden administration, the Federal Trade Commission has just announced a new rule to require disclosure of so-called "junk fees" in certain ticket prices. The Consumer Product Safety Commission has issued a recall of a brand of Christmas light controllers due to fire hazard.

The Consumer Financial Protection Bureau has the power to accept complaints regarding banks and other financial institutions. A few months ago it filed a proposed order against a company that has a years-long record of violating several federal laws by tricking student loan borrowers into paying much more than they owed.

Consumer protection is one of the essential services of government. I hope the incoming administration, which is talking about saving money by cutting agencies like these, recognizes that. Contact Merilee Dannemann through www.triplespacedagain.com.