Kaiser Permanente Insurance Claim Denials

Insurance Claim Denial, 'Claim denied' words on wooden blocks.

Kaiser Foundation Health Plan, part of the larger Kaiser Permanente consortium, is the largest managed care company in the country, with nearly 12 million customers nationwide. Since Kaiser is non-profit, they say their policyholders needn’t worry they will fall victim to bad faith insurance practices other companies might engage in to maximize their profit. But it flies in the face of logic to believe a non-profit health insurance company won’t be concerned about costs and its bottom line. One quick look at the large cash reserves Kaiser holds onto that it could be spending on patient care speaks volumes about how non-profit corporations operate, and Kaiser does in fact run many for-profit divisions as well.

Kaiser’s brushes with bad faith insurance practices are well-documented. In one case, a class action prevailed in court on behalf of patients whose reconstructive surgery claims for excess skin removal procedures following bariatric weight loss surgery were turned down (Gallimore v. Kaiser Foundation Health Plan, Inc, case no. RG12-616206). Another class action was fought on behalf of children with autism to see that Applied Behavior Analysis therapy would be covered under Kaiser health plans. California’s Department of Managed Care, meanwhile, acted on numerous complaints regarding Kaiser’s refusal to provide patients with timely mental treatment.

If you are receiving Medi-Cal coverage through Kaiser, you don’t have to settle for substandard medical care or be the victim of bad faith insurance practices. If your claim for a medical procedure was unreasonably denied based on excuses that the procedure is experimental or not medically necessary that mask the insurer’s true motive of denying the claim to save money, then you could be entitled not only to the benefits due under your policy but also significant compensation for the additional harm Kaiser’s bad faith conduct has inflicted on you. This can include punitive damages in appropriate cases, which can greatly increase the size of your monetary award and hold Kaiser fully accountable for the damage done.

Kaiser and Medicaid

Kaiser is an HMO – the nation’s largest, in fact – and its operation as an HMO makes it a perfect vehicle to serve people on Medicaid such as Medi-Cal in California, which is also HMO-based. We have already noted that Kaiser is the largest HMO in the country, and it is additionally significant to note that California has the highest percentage of people covered by HMOs of any state in the nation.

When it comes to Medi-Cal, Kaiser is as enormous in California as it is across the United States. Whereas an insurance company with a massive California presence like Anthem Blue Cross provides Medi-Cal plans in 16 California counties, Kaiser doubles that number, serving Medi-Cal recipients in 32 of California’s 58 counties. You’ll find Kaiser facilities and health plans offering to serve Medi-Cal beneficiaries in all of the following counties in California:

Southern California

Imperial County
Kern County
Los Angeles County
Orange County
Riverside County
San Bernardino County
San Diego County
Tulare County
Ventura County

Central California

Fresno County
Kings County
Madera County
Mariposa County
San Joaquin County
Stanislaus County

Northern California

Alameda County
Amador County
Contra Costa County
Diablo County
El Dorado County
Marin County
Napa County
Placer County
San Francisco County
San Mateo County
Santa Clara County
Santa Cruz County
Solano County
Sonoma County
Sutter County
Yolo County
Yuba County

As mentioned earlier, Kaiser has been called out numerous times by various California courts and state agencies like the Department of Managed Health Care for wrongful denials of coverage for important medical services. These denials are bad enough when they hit people who might be able to cover the treatment out-of-pocket and then seek reimbursement through grievances or legal action. But when bad faith actions are taken through a Kaiser Medi-Cal plan, they hit people who can ill afford to have their claim for medical treatment denied. Medi-Cal serves the lowest-income Californians and the state’s most vulnerable categories of people, including the elderly, disabled, pregnant women, and children in foster care.

Legal Help May Be Needed to Effectively Deal With Wrongful Denials of Medical Care

An unreasonable delay or denial of a healthcare claim can take a devastating toll on anyone in need of medical care, including especially a state’s most vulnerable residents relying on medical care through an HMO like Kaiser Permanente. An insurance law firm with experience taking on Kaiser and other insurers for wrongful claim denials can help ensure that your insurance company behaves as it should, providing the coverage for medical care which should be their primary mission.