Protect Patients From Insurers' Business Tactics

For Immediate Release
Sept. 25, 2009  

Contact: Pam Udall  
phone: (512) 370-1382
cell: (512) 413-6807  

Brent Annear
phone: (512) 370-1381
cell: (512) 656-7320  

The Texas Medical Association (TMA) is urging President Obama and the U.S. Congress to fix what's wrong and keep's what good in America's health care. "On the list of things that need to be fixed are the tactics health insurers use to avoid paying our patients' health care costs," said TMA President William H. Fleming III, MD. "It's time Congress holds health insurers accountable for the promises they make to the patients who pay ever-increasing premiums for less and less coverage."

The association sent a letter to President Obama and members of the Texas Delegation to Congress asking them to support measures in current health system reform legislation that would provide greater transparency and accountability in the health insurance industry. The four specific issues TMA is asking Congress to support include these:

Prohibition on insurers' rescission of health insurance coverage,

  • Prohibition on pre-existing condition policy exclusions,
  • Standardization of consumer disclosures, and
  • Transparency of health insurance premiums and the amount going to direct patient care.

Prohibition on Insurer Rescission  

TMA supports prohibitions in the Senate Finance Committee Chairman's Mark and in HR 3200 on insurer rescission of health insurance coverage. "These changes are necessary to ensure patients who buy health insurance coverage can get the care they need when they need it most," said Dr. Fleming.

Today health insurers rescind insurance policies upon discovery of alleged misrepresentations in the patient's initial application for insurance. When coverage is rescinded based on a misrepresentation on the application, the premium paid to that point in time is refunded and all coverage is rescinded, leaving the patient responsible for paying for all health care services past and present. Health insurers today can rescind coverage based solely on honest mistakes or misunderstandings in the completion of insurance applications. "Health insurance applications are so confusing, sometimes people make honest mistakes in completing them," added Dr. Fleming. "Insurers should not be allowed to risk a patient's health and life over technicalities."

Prohibition on Pre-Existing Condition Policy Exclusions  

TMA conducted 16 House Call meetings across Texas this summer with more than 3,000 patients and physicians participating. One common theme from House Call participants was a prohibition on health insurance policies that contain a pre-existing condition exclusion. "We heard over and over from Texas patients - some even in tears - that Congress must stop health insurers from denying them coverage because of a pre-existing condition," said Dr. Fleming. "The prohibitions in the Senate Finance Committee Chairman's Mark and HR 3200 are good first steps in allowing more patients to be eligible for health insurance."

Standardization of Consumer Disclosures by Insurers  

TMA supports the concepts expressed in the Chairman's Mark other legislation that "would require that insurers provide employers and patients with uniform, meaningful, easy-to-understand, and actionable information about their products," said Dr. Fleming.

Purchasing health insurance coverage today is increasingly complex. Health insurance companies offer a wide range of plans with different benefits, exclusions, and costs. Patients find it nearly impossible to decipher a health insurer's sales literature and then figure out how to make a direct, product-to-product comparison.

"Employers and patients need accurate, current, and honest information on copayments, deductibles, and health plan networks to make decisions in today's health care market," added Dr. Fleming.

Standardized and reliable nutritional labeling has made it much easier for patients to make better food choices. Through the use of standardized labeling, consumers can examine 20 different boxes of cereal and easily compare the product ingredients (benefits), and other facts such as the number of calories and percentage of fat, sodium, sugar, or protein. "We believe the same standardized system could aid employers and patients when shopping for health insurance," says Dr. Fleming. The "health insurance product label" would enable employers and patients to compare health plans easily based on standardized measures of value. "We supported the health insurance product label concept in the 2009 Texas Legislature," added Dr. Fleming.

Transparency of Health Insurance Premiums/Amount Going to Direct Patient Care  

For many employers and their employees, yearly health insurance premium increases are unsustainable. No one feels this challenge more acutely than small businesses, which are the largest generators of new jobs today. "We see this problem quite acutely and personally - physicians are paying more money each year to provide health insurance coverage for our own employees," said Dr. Fleming. "We also know that patients now pay more money out of their own pocket for their health care, and they pay more for health insurance."

The big question is this: How much of the health insurance premium dollar is actually going to direct patient care services? Health plans call money spent on health care the "medical loss ratio."  TMA urged Congress to look at the medical loss ratio disclosure language found in several pending pieces of legislation. In addition, it is important to standardize the formula for calculating the medical loss ratio to permit company-to-company comparisons.

TMA is the largest state medical society in the nation, representing nearly 44,000 physician and medical student members. It is located in Austin and has 120 component county medical societies around the state. TMA's key objective since 1853 is to improve the health of all Texans.

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Last Updated On

May 06, 2016

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