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State fines Excellus nearly $1 million

By WILL ASTOR - 4/19/2012 5:32:16 PM

The state Department of Financial Services has hit Excellus BlueCross BlueShield with a nearly $1 million fine for improperly denying emergency department coverage and failing to explain coverage details to policy holders.

The infractions, which occurred from 2003 and 2007, were uncovered in a Department of Financial Services review of the insurance carrier’s market practices during the four-year period.

Excellus blamed 116 instances of improperly denied coverage for ED services on a systems error that occurred in cases where policy holders already had paid providers when claims were processed. The company has advised the Insurance Department that it has reimbursed the shorted policy holders, Financial Services Department officials said.

The state regulator also found Excellus had not provided policy holders with a required explanation of drug coverage in 337,689 instances. New York law calls for insurers to mail explanation of benefit notices with each claim processed.

Fines for both sets of infractions totaled $995,000.

“Consumers need to understand what their insurance covers, what it doesn’t cover and how they can challenge an insurer when a claim is denied,” Financial Services Department superintendent Benjamin Lawsky said in a statement.

“While this fine reflects the serious nature of these violations, I am encouraged by Excellus’s commitment to take corrective actions. The insurer worked with the department to resolve this issue and has committed to improving its performance going forward.”

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