Some elements of the health insurance industry have resisted legislative mandates, and others say health plans generally do a good job of handling consumer grievances. Patient advocates see it differently. Kaiser officials said they recognized the frustration Al-Warith and his wife felt but disagreed with the complaint that Kaiser was unresponsive. The internal appeals that health plans offer consumers often reward perseverance. The panel decided unanimously in her favor.
Few consumers take the formal appeals route.
CareFirst and FreeState Health Plan, an affiliated Blue Cross and Blue Shield HMO, processed more than half a million medical claims last year and received only 703 grievances, said Antoinette Hopkins, director of member services for the two HMOs. Though health plans may explain their grievance procedures in handbooks sent to enrollees, some consumers say they are not aware of their rights or responsibilities when a dispute arises. Sometimes, what is presented as a fair outside appeals process can be far from impartial. That was the California Supreme Court's comment last year on an arbitration system Kaiser Permanente has used to resolve disputes in that state. Kaiser has taken steps to improve the arbitration system, and the HMO wasn't necessarily responsible for the delays, Kaiser Vice President Pauline Fox said.