The HMO Task Force handled 17 consumer appeals that year. In 1996, the most recent year for which figures were available, about 4,000 consumers filed appeals with their HMOs, state records show. In those appeals, the HMO reversed its decision in favor of the consumer about half the time. Hundreds of other appeals were withdrawn, mutually resolved or upheld in favor of the HMO, according to state records. Of those, about 2,000 people who didn't get what they wanted from their HMOs, only a handful took the next step and appealed their cases to the state.
Patients often drop their appeals and pay their own medical expenses, doctors say.
Many patients and doctors also do not know about the state task force, which isn't widely publicized. While it's easy to say an insurance company should cover any and all medical treatments, some doctors and HMO officials say we shouldn't expect such coverage without substantial cost hikes. In general, people want to think that everything that can be done, should be done. Her HMO, Care Choices, refused to approve or pay for the surgery, partly because Zoltowski was overweight, according to the HMO's guidelines for the procedure. The task force ordered her HMO in June to pay for the surgery, which is scheduled for later this month.