Policyholders whose health insurers have rejected claims and who have exhausted internal appeals would be able to access the ombudsman office for assistance.”This is a huge problem just begging to be abused. You will be forbidden to get help until you have exhausted all internal appeals. This will create a strong finance incentive for insurance companies to make the appeal process a long painful bureaucratic nightmare. The more complex and time consuming the appeal process the better for the insurance company because it would deny the patient access to professional consumer advocate assistance.
In affect this will replace the problems of “recession” and “pre-existing condition” with the new problem of “death delay.” The hope is that the patient (who would normally be very sick or dealing with a severe medical issue) will either give up in frustration or die before the many complicate internal appeals are exhausted.
Fortunately, Senator Bingaman and Senator Menedez have offer different amendments to help improve the problem by allowing individual to seek help from the ombudsman's office before exhausting internal appeals.
Menedez C#7 is the better of the two amendments and is described as:
Allow policyholders to access the ombudsman for assistance in pursuing internal appeals with their health plans.Bingaman C#5 is weaker but would be a much needed improvement. It is described as:
This amendment would authorize a policy holder to access ombudsman services: (1) if their internal appeal lasts more than three months or (2) if their appeal involves a life threatening issue.All the consumer protections in the world are worthless unless there is a strong regulator and consumer advocate to enforce them. As it is currently written the ombudsman's office is a massive gift to the for-profit insurance companies and would encourage bad behavior.
Of course, If Baucus' bill gave people the option of buying a non-profit insurance plan overseen by the government (a public option), they would not need to worry about protecting themselves from a for-profit insurance industry which makes money by denying people's claims.