Kathleen G. Kane - Pennsylvania Office of Attorney General - Protecting Pennsylvanians

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Dec. 11, 2009

Attorney General Corbett announces $500,000 settlement with HealthAmerica over rejected emergency room treatment claims

ER-366X19HARRISBURG - A Harrisburg-based health insurance company accused of improperly rejecting claims for emergency room treatment has agreed to reprocess claims and pay bills for more than 600 Pennsylvania consumers as part of a settlement with the Attorney General's Health Care Section.

Attorney General Tom Corbett said the Assurance of Voluntary Compliance (AVC) was reached with HealthAmerica Pennsylvania Inc. and HealthAssurance Pennsylvania Inc., of 3721 TecPort Drive, Harrisburg.

Corbett said HealthAmerica allegedly rejected claims for emergency room treatment by using standards that were higher than the guidelines outlined in their insurance plans.  The plans administered by HealthAmerica include a "prudent layperson" standard, where claims are payable when a reasonable person, experiencing similar signs or symptoms, would seek emergency medical care.

"These consumers went to emergency rooms because they believed they needed immediate care for serious medical conditions - something that is supposed to be covered under the HealthAmerica plans," Corbett said. "Using higher standards to reject these claims allegedly left hundreds of Pennsylvania consumers facing thousands of dollars in medical bills that should have been paid by their insurance."

Corbett said a review of HealthAmerica emergency room claims submitted between 2001 and 2007 identified 631 Pennsylvania consumers whose claims appeared to have been improperly denied.  As the result of the consumer settlement, HealthAmerica will reprocess and pay $445,981 worth of claims to address bills for medical treatments that were initially rejected.

Additionally, Corbett said that HealthAmerica is required to change its claims review procedures in order to ensure that adequate information is obtained and proper standards are used to determine whether claims for emergency medical services should be approved or rejected.

HealthAmerica will also pay $10,000 in civil penalties, along with $50,025 to cover the cost of the investigation, attorney fees, court costs and future public protection and consumer education activities by the Attorney General's Office.

The Assurance of Voluntary Compliance was filed in Dauphin County Court of Common Pleas by Deputy Attorney General Timothy E. Gates of the Attorney General's Health Care Section.

Corbett said that consumers with problems or concerns about claims involving HealthAmerica, or other health insurance companies, can call the Attorney General's Health Care Hotline at 1-877-888-4877 or file an online complaint using the Attorney General's website: www.attorneygeneral.gov (Click on the "Complaints" button near the top left corner of the website and select "Health Care Complaints" from the menu list).

Corbett thanked the Pennsylvania Insurance Department for their cooperation and assistance with this investigation.