"Why do I have to do the insurance company's work to get my claim paid?"

This is another question that we hear a lot. Whether or not you are dealing with your own insurer or someone else’s insurer, be prepared to be involved in the claim.

Here's why: Processing a claim is rarely one-sided, and your participation is needed.

You may be asked to provide information, statements, photos, receipts or other things to support your claim.

You may be asked to attend what's called an "exam under oath" or go to an independent medical exam to verify claim details and injuries.

In order to promote a resolution to your claim, we recommend that you actively be involved, ask questions, and be ready to help with processing your claim.

What you can do when your health insurer says no

Little-known fact: When your health insurer denies a treatment or won’t cover a bill, that’s not necessarily the final answer. In most cases, you can appeal that decision.
Even if the insurer says no, consumers can often appeal to an independent group with the power to overrule the company. Nearly a quarter of Washingtonians who do that end up winning.
Our office has posted an easy-to-use guide to filing appeals on its website at www.insurance.wa.gov/your-insurance/health-insurance/appeal. Since we're the insurance regulator for Washington state, it's designed for Washington residents, but many of the tips apply more broadly.
The guide has been recently overhauled to make it easier to use. It includes step-by-step tips, examples, and downloadable letters that consumers can fill out and send to their insurer.
We also experts on staff who can help Washington state consumers with their appeal. They can be reached at 1-800-562-6900 or AskMike@oic.wa.gov.

And if you don't live in Washington state, here's a handy map showing how to contact your state's insurance regulator.

Large health insurer surpluses could help ease premiums

The News Tribune of Tacoma and the Bellingham Herald this morning ran an op-ed column by Commissioner Kreidler, talking about the fact that -- under current law -- our rate reviews of health premiums have to ignore the billion-dollar surpluses that some non-profit health insurers are sitting on.

From the op-ed:

Two of this state’s largest insurers – Premera Blue Cross and Regence BlueShield – are sitting on surpluses totaling $2.2 billion. In fact, their surpluses grew almost a quarter-billion dollars in the first nine months of 2012 alone.


As the state’s insurance regulator, I review insurance premiums. If they’re unjustifiably high, I tell companies they cannot charge that much. This is a critical protection for Washington consumers.

But here’s the elephant in the room: Under current law, I am barred from taking those surpluses into account when I review rates. This is despite the fact that regulators in nearly a dozen other states, including Oregon, have the authority to do so.

We're seeking legislation -- House Bill 1349 -- that would allow us to take surplus into account when the rates are reviewed.

By factoring surpluses into rate reviews, I can help protect consumers from sticker shock in their health care premiums, while still ensuring that carriers are financially healthy. It would be a tragedy – both for the economy and for individuals – if lawmakers chose to put the interests of insurance companies ahead of their constituents.

WA insurers and agents fined $2 million in 2012

From a news release we issued minutes ago:

Insurance Commissioner Mike Kreidler issued more than $2 million in fines against insurers, agents and brokers in 2012.


“Ideally, we’d have full compliance and no fines,” said Kreidler. “But the reality is that sometimes it takes a fine to get a company to address problems. And in many cases, these fines were accompanied by compliance plans aimed at making sure the problems don’t recur.”

The fines totaled $2,033,990. Violations included charging customers for coverage they’d never agreed to, charging unapproved rates, allowing unlicensed staffers to sell policies and failing to register with the state.

“Fortunately, these cases are the exception,” said Kreidler. “Most companies, agents and brokers follow the rules.”

The agency posts all disciplinary orders – including those that don’t include fines – at www.insurance.wa.gov/orders/enforcement.asp.

The total for 2012 was higher than the previous year’s $1.4 million.

Fines collected by the insurance commissioner’s office do not go to the agency. The money is deposited in the state’s general fund to pay for other state services.

Over the past 12 years, Kreidler has issued more than $15 million in fines for violations of Washington’s insurance laws.

Hearing set to consider request to buy Soundpath Health

We've scheduled a hearing on March 1 at 10 a.m. to consider Catholic Health Initiative's request to acquire Washington-based Soundpath Health Inc.

From our public notice about the hearing:

Catholic Health Initiatives (CHI) through its subsidiary, CollabHealth Plan Solutions, is proposing to acquire common shares of Soundpath Health from Soundpath’s current owners, Northwest Physicians Network and Physicians of Southwest Washington. The acquisition would allow CHI and CollabHealth Plan Solutions to own approximately 56 percent of common shares of Soundpath Health and become controlling entity of Soundpath Health.

Catholic Health Initiatives is a national nonprofit health system with headquarters in Englewood, Colo. The faith-based system operates in 19 states and includes 81 hospitals; 40 long-term care, assisted, and residential-living facilities; two community health-services organizations; two accredited nursing colleges; and home health agencies. In fiscal year 2012, CHI provided more than $715 million in charity care and community benefit, including services for the poor, free clinics, education and research. With total annual revenues of more than $10.7 billion and approximately 86,000 employees, CHI ranks as the nation’s second-largest faith-based health system.

If approved, CHI through CollabHealth Plan Solutions, Northwest Physicians Network and Physicians of Southwest Washington would be co-owners of Soundpath Health.

The public is notified that all interested parties may submit letters of support or concerns or objections and/or may participate in the hearing by appearing in person or by telephone at no charge.

To view the Notice of Hearing, which includes advice on how to participate in the hearing process, and to view all documents filed in this matter including the Purchase Agreement between the parties, and all other documents such as organizational charts and finances, current and past states’ regulatory actions and other litigation filed in this proceeding, go to Soundpath Health #13-0039 at
http://www.insurance.wa.gov/laws-rules/administrative-hearings/judicial-proceedings/s-t/.

Insurance tips: "My insurer wants more money due to an 'audit.' What's that?"

Q: I paid my business policy premium, and now, after the policy period is over, the insurer wants more premium because of an "audit." What's going on?

This is a common question.

This issue deals with the audit provision found in the typical commercial policy. Because businesses may experience both decreases or increases due to business cycles, estimated premiums are commonly used in commercial policies when they are first issued, with an annual audit option to identify any premium that needs to be added or subtracted due to the business cycle. Insurers may or may not decide to exercise their right to audit.


The good news is that the audit, while it may increase your premium for the prior business period, could also decrease it.

Job openings: Market analyst and financial analyst

We have three job openings, both in our main office in Tumwater, Wash.

One is for a financial analyst. Duties include examining and analyzing insurance company financial filings and data to discern their financial condition, difficulties, trends and compliance with laws and rules.

Required qualifications include a bachelor's degree with major study in finance, business administration, economics or accounting; a CPA license or Accredited Financial Examiner credential, and three years of professional experience in accounting or auditing.

For a full list of duties, qualifications, and application information, please see the full job listing.

The other job openings -- two of them -- are for market analysts. These people -- this won't be surprising -- conduct market analysis and participate in data surveys, using data from various sources, including other states' insurance departments. They also review company information on Facebook, Twitter, carrier websites, agent sites and blogs.

The market analyst jobs require a bachelor's degree in business administration or a related field, although work experience may also be submitted. They also require two years of experience in life, helath or property and casualty insurance company operations. For details, application info, etc., please see that full job listing.

Thanks for your interest!