State consumers sue health insurer Centene Say in-network doctors could not be found

Consumers in Illinois and other states are suing health insurance giant Centene and its Chicago-based subsidiary Celtic Insurance Co., alleging the insurers defrauded them by overcharging them for plans that didn't deliver the benefits they promised.

Six consumers, including two in Illinois, are seeking class-action status for the lawsuit, which was filed Friday in U.S. District Court for the Northern District of Illinois.

They allege that the companies, which sell plans called Ambetter on the Affordable Care Act exchange, give customers incorrect lists of provider networks. A provider network is a group of doctors and other health care workers who have contracted with an insurance company to provide care to its members.

The consumers said, in some cases, they called doctors listed in the network directories only to find that almost none of them took Ambetter plans. As a result, consumers faced delays in treatment, couldn't get treatment or had to pay out-of-pocket for other doctors because they couldn't find any in Ambetter's networks, they allege in the lawsuit.

"Plan members have difficulty finding an in-network provider and sometimes cannot find any provider who accepts Ambetter insurance," according to the complaint.

The lawsuit also alleges that Ambetter plans "routinely refuse to pay for medical services and medications that the plan purportedly covers." That can leave patients paying for medical bills without insurance, the lawsuit alleges. In some cases, the bills are sent to collections, leaving consumers "stuck between disputing the bill for years and paying for medical care that the Ambetter plan purportedly covered," according to the lawsuit.

The lawsuit accuses the insurance companies of violating the Racketeer Influenced and Corrupt Organizations Act, of unjust enrichment and of violating the Illinois Consumer Fraud and Deceptive Business Practices Act, among other things.

Centene defended itself in a statement Monday, saying that it and its subsidiaries have worked, since the Affordable Care Act became law, "to help members and their families gain access to comprehensive, affordable and high-quality Marketplace health plans."

"This lawsuit is merely one more attack on the Health Insurance Marketplace and the ACA itself," Centene said in the statement. "Centene will fight this lawsuit vigorously and will continue to uphold the important purpose of the ACA to improve the health of our communities, one person at a time."

More than 2 million people have Ambetter plans, according to the lawsuit, and the plans are sold on Affordable Care Act exchanges in 26 states. In Illinois, about 54,000 people have Ambetter plans, according to recent rate filings by the company.

The lawsuit alleges that the insurance companies often targeted low-income consumers, advertising the Ambetter plans to people who no longer qualified for Medicaid, which is a state and federally funded health insurance program for people with low incomes.

One of the Illinois consumers who filed the lawsuit, Alden Henriksen, alleges that after he signed up for an Ambetter plan in 2019 he called dermatologists on Ambetter's list of in-network providers only to find that almost none of them accepted Ambetter. He then called the general practitioner in his area that Ambetter assigned him to, and that doctor also did not take Ambetter, he alleges.

The other Illinois plaintiff, Melody DeSchepper, bought an Ambetter plan in January 2021 after she lost her job and needed insurance, according to the complaint. She alleges that she called 29 providers that were on Ambetter's list of in-network providers or were recommended by Ambetter's assistance line, and none of them took Ambetter.

The plaintiffs are seeking damages for the money they were allegedly overcharged for Ambetter's plans as well as a permanent injunction that would put "an end to defendants' fraudulent and unlawful conduct," according to the lawsuit.

Celtic is among a number of insurance companies that have proposed raising rates in Illinois for individual plans, including those sold on the ACA exchange, for 2023. Celtic has proposed raising its rates by an average of 13.7% in Illinois for next year.