Beware Of "Limited Benefit Health Insurance Plans"

New York is cracking down on companies that sell limited benefit health insurance plans in ways that mislead people into believing they have full health insurance coverage. As a result, the New York State Insurance Department has moved to protect New Yorkers by stopping one company from selling the product in New York and from advertising nationally and is examining the marketing practices of all companies selling this product.

"Many New Yorkers are desperate for affordable health insurance”, said Governor David Paterson. “More than 2.5 million have no coverage, and with tens of thousands losing their jobs, that number is growing. Unfortunately, some businesses are taking advantage of that need to sell limited health insurance in ways that mislead consumers into believing they are getting full coverage. If they get seriously ill, consumers who buy this product can find themselves with huge bills they are unable to pay. New York will not allow disreputable businesses to take advantage of consumers," Governor Paterson said.

Governor Paterson announced the Department fined one company, American Medical and Life Insurance Company (AMLI), $700,000 for numerous violations, and imposed new restrictions on the company. The company can no longer sell its limited benefit products in New York, and has been forced to pull its nationwide television commercial. The commercial was the company's main marketing tool.

Limited benefit health insurance plans normally provide less than comprehensive hospital/medical coverage, but with healthcare bills being the leading cause of personal bankruptcy filings nationally, many consumers searching for affordable coverage buy limited benefit health plans as one way to insure against potential liability. Limited benefit health plans may leave consumers with large medical bills. If injury or illness occurs and an insured files a claim, they may find that they have less coverage than they thought (see Appendix A for comparisons).

A sampling of complaints received by the Insurance Department about AMLI's coverage illustrates this gap:
* A Rochester-area woman purchased health insurance from a telemarketer and agreed to have the $419 a month premiums paid by automatic charges to her credit card. She was provided no written documents spelling out details of the coverage. Soon afterward, she needed hospitalization, which cost nearly $28,000. It turned out the policy, sold by an agent unlicensed in New York, paid only $1,164 of the expenses. AMLI paid in full only after the Department intervened.
* A young man suffered a stroke at the age of 36. AMLI paid only $250 toward his medical bills. The insured had to pay a total of $29,917.04.
* A woman went to the emergency room with stomach pains and a day later received an appendectomy. AMLI paid $1,416.10, leaving the insured a balance of $19,437.59.
* After being given misleading coverage information by an agent, a man purchased a limited medical benefit plan from AMLI. He understood, and the information sent to him indicated, that the plan required a $10 co-pay for doctors/specialists (10 covered visits per family member per calendar year) and would pay $25,000 for hospital inpatient services (100 days maximum per calendar year). Therefore, he was surprised to find that AMLI only paid $39.65 toward an ENT bill for $237.42 and $250.00 toward an inpatient hospital bill for $3092.73. His total medical bills were $4197.79 and AMLI paid $807.29. With regard to the hospital stay, AMLI contended that the insured should have known that a $250 per day limit applied to the $25,000 limit for hospital inpatient services, since the maximum days were limited to 100. AMLI agreed to pay only after the Department intervened.
* A man bought a limited medical benefit plan issued by AMLI. When he bought the policy, he was told that there would be a $20 co-payment for doctor's visits and a $100 co-payment for emergency room services. He was not made aware of any other limitations on his benefits and never received a Summary Plan description from the carrier. AMLI paid less than he expected for two hospital emergency room visits. The first time, the bill was $1,720.61 and AMLI paid $150. AMLI denied the second claim for $731 saying the emergency room benefit maximum had been met because it was his third visit to the emergency room that year. Only when he complained to the company was he told that emergency room benefits were limited to a maximum of two visits per policy year and a maximum of $150.00 per visit. After the Insurance Department intervened, the company agreed to pay the remainder of his claim.

Consumers with insurance questions or concerns can call the Insurance Department's consumer hotline at 1-800-342-3736. The hotline is open from 9 a.m. to 4:30 p.m. Monday through Friday. Consumers may also ask questions or file complaints at the Insurance Department's website, www.ins.state.ny.us.