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Consumer Advocates Call for Governor to Make Good on His Promise to Protect Patients From Illegal Cancellations of Health Insurance
Date:3/27/2008

Recently, the Department of Managed Health Care released draft regulations that clearly require a showing of willful misrepresentation before a policy is rescinded:

(b) No subscriber contract shall be cancelled or rescinded because of a misstatement or omission in the coverage contract, unless the misstatement or omission is a result of the applicant's willful misrepresentation and the omitted information would have been a basis for denial of coverage pursuant to the plan's underwriting criteria, guidelines, policies, and procedures.

In a survey[3] released on March 22, 2007, the DMHC sharply criticized Blue Cross of California for "routinely rescinding health insurance policies in violation of state law." In the report, the DMHC argued that SS 1389.3 requires a showing of willful misrepresentation in all cases before a health plan may rescind any enrollee's coverage.

The survey found that out of 90 patient complaints reviewed, Blue Cross illegally rescinded coverage in each case by failing to show willful misrepresentation. According to page two of the report,

"[i]n all 90 case files, there was no evidence [that Blue Cross], before rescinding coverage, investigated or established that the applicant's omission/misrepresentation was willful."

On page four of its amicus curiae brief for the Hailey v. Blue Shield appeal, the Department clearly articulated that,

[b]ecause of the catastrophic consequences of losing health care coverage, and in furtherance of the consumer protection purpose of the Knox-Keene Act, the Legislature enacted SS 1389.3 . . . .[which] expressly prohibits post-claims underwriting and allows a health plan to rescind overage only in cases where it has met its burden of demonstrating that the consumer willfully misrepresented his or her health history. (emphasis added)

On page 14, the Department concluded that a showing of willful misrepresentation is necessary even if the health
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SOURCE Consumer Watchdog
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