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Exclusive: WellPoint routinely targets breast cancer patients | Reuters

(Reuters) - Shortly after they were diagnosed with breast cancer, each of the women learned that her health insurance had been canceled. There was Yenny Hsu, who lived and worked in Los Angeles. And there was Patricia Reilling, a successful art gallery owner and interior designer from Louisville, Kentucky.

U.S.  |  Health  |  Healthcare Reform

Neither of these women knew about the other. But besides their similar narratives, they had something else in common: Their health insurance carriers were subsidiaries of WellPoint, which has 33.7 million policyholders -- more than any other health insurance company in the United States.

The women paid their premiums on time. Before they fell ill, neither had any problems with their insurance. Initially, they believed their policies had been canceled by mistake.

They had no idea that WellPoint was using a computer algorithm that automatically targeted them and every other policyholder recently diagnosed with breast cancer. The software triggered an immediate fraud investigation, as the company searched for some pretext to drop their policies, according to government regulators and investigators.

Once the women were singled out, they say, the insurer then canceled their policies based on either erroneous or flimsy information. WellPoint declined to comment on the women's specific cases without a signed waiver from them, citing privacy laws.

Any idiot can face a crisis - it's day to day living that wears you out.
by ceebs (ceebs (at) eurotrib (dot) com) on Fri Apr 23rd, 2010 at 05:28:11 AM EST
[ Parent ]
That's uncannily and almost unexpectedly like - a death panel.
by ThatBritGuy (thatbritguy (at) googlemail.com) on Fri Apr 23rd, 2010 at 08:08:15 AM EST
[ Parent ]
but its privatised so its ok,

dont yew kno nuffink?

Any idiot can face a crisis - it's day to day living that wears you out.

by ceebs (ceebs (at) eurotrib (dot) com) on Fri Apr 23rd, 2010 at 08:14:19 AM EST
[ Parent ]
re: "The software triggered an immediate fraud investigation"

Insurance production and marketing is regluated in and by each of the several states. Definitions of "fraud" as pertains to enforceability of the contract differentiate obligations of the counterparties, issuer and insured. In some respects the Patient Protection and Affordability Act seeks to unify formally states' statutes by affirming federal authority and establishing minimum standards of liability according to USC.

In general,

Insured may not...
knowingly present an insurer documentation or communication in support of a claim that contains false or misleading information concerning a matter material to a claim or an insurance application

Issuer may not...
misrepresent pertinent facts or policy provisions that relate to a claim or coverage at issue or in dispute. Fraudulent acts are

  • knowingly fail to return to an insured money or premiums paid for a policy not ultimately provided
  • knowingly make a false statement in reference to any insurance application
  • willfully collect as an insurance premium a sum in excess of the premium applicable to the insurance
  • misappropriate or withhold unreasonably funds received that represent premiums or benefits
  • act as an insurance producer, broker, or adjuster without appropriate license
  • place insurance with an insurer not regulated by the state
  • refuse an order by a state commissioner to produce for examination all policies and other documentation evidencing the insurance and premium amounts paid

"Unfair discrimination" is illegal but not necessarily a fraudulent act: It is illegal to discriminate unfairly between individuals of the same class and life expectancy for the rates charged, dividends, other benefits payable, and any other condition of life insurance or life annuity contract.

To be "fair," issuer's treatment of one is applicable to all individuals of the same class and life expectancy.


Diversity is the key to economic and political evolution.

by Cat on Fri Apr 23rd, 2010 at 09:32:57 AM EST
[ Parent ]


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