Clark Insurance

Dear
[redacted],
Please
see our response to complaint #[redacted] from [redacted] for [redacted] that was received by us on January 19, 2016.
We
reviewed the renewal notice that was sent for [redacted]’s
policy in September 2014, which was for the plan year...

beginning January 1,
2015.  It was found the letter stated
that the plan from 2014 would no longer be offered, but did also state that [redacted] would be automatically enrolled onto a different plan with Coventry. 
The
first request for termination of the policy that we located was from November
9, 2015.  Our guidelines allow for
retroactive terminations of policies going back 60 days from the first request.  As such, we were able to grant a termination
date of September 9, 2015.  With the
retroactive termination date we will issue a prorated refund for the month of
September as well as refunds for the total amount paid for the October and
November coverage.  Since the premiums
were drafted from a bank account through Electronic Funds Transfer, the refunds
will be deposited directly into the same account using the same method.  The standard timeframe for refunds to be
deposited is 7 to 10 business days. 
We
did have a request reviewed to determine if we could go back farther than 60
days, but as there was no indication that Coventry had been contacted to cancel
the policy before November 9, 2015, the request was denied.  Also, Coventry does not provide reimbursement
to individuals for the time they spend on the phone with our
representatives. 
We
take customer complaints very seriously and appreciate you taking the time to
contact us and giving us the opportunity to address [redacted]’s
concerns.  If there are any additional questions regarding this particular
matter, please contact the Executive Resolution Team at [redacted]@[redacted].com.
Regards,
Chris
B[redacted]
Complaints
and Appeals Consultant
Executive
Resolution Team

Dear
[redacted],
"Times New Roman"">Please
see our response to complaint #[redacted] for [redacted] that was received by us on February 2,
In
reviewing [redacted]'s policy, it was noted that she is covered on a
self-insured plan through the [redacted]
([redacted]). We found that an authorization
had been requested for a procedure used to treat lipodystrophy. The request was reviewed by our Medical
Director, Heather U[redacted] MD, and the request was denied.
The
Plan Brochure for [redacted]'s plan outlines the process for requesting reconsiderations
of decisions that the person does not agree with. The relevant section begins on page and
continues through page 93. The brochure
states that the first level of appeal is initiated with [redacted] by writing to them
at [redacted], P.OBox [redacted], Independence, MO [redacted] and including supporting
documentation. It goes on to say that if
the person does not agree with the [redacted] decision, the next step in the review
process can be started by writing to the Office Of Personnel Management (OPM)
at United States Office of Personnel Management, Healthcare and Insurance,
Federal Employee Insurance Operations, Health Insurance 2, E Street NW,
Washington, DC 20415-3620. Filing to OPM
is the last level of administrative appeals, so beyond that the next level of
recourse is to file a lawsuit. Please
refer to the attached Plan Brochure for the full instruction on filing appeals
and reconsiderations
Lastly,
we were able to locate the privacy policy for [redacted]. As they are a self-insured employer group,
with Coventry Health Care acting as a business associate, [redacted] maintains the
privacy policy and is responsible for providing the health information that
[redacted] is requesting. The form
that can be used to request that information is attached, as is the privacy
policy. The form must be completed in
full and can then be sent to [redacted], ATTN: Access Request, P.OBox [redacted], Independence,
MO [redacted]
We
take customer complaints very seriously and appreciate you taking the time to
contact us and giving us the opportunity to address [redacted]'s
concerns. If there are any additional questions regarding this particular
matter, please contact the Executive Resolution Team at [redacted].com
Regards,
Chris
B[redacted]
Complaints
and Appeals Consultant
Executive
Resolution Team

Dear
[redacted],
Please
see our response to complaint #[redacted]
for [redacted]
that was received by us on November 30, 2015.
It
was found that [redacted] was not considered as an authorized representative
to act on his son’s behalf.  We were able
to reach out to his son, [redacted], to obtain the necessary authorization for this
situation and have mailed him a form that can be completed to authorize his
father to act on his behalf in the future. 
Upon
receiving the authorization from [redacted], we provided the details of the
resolution reached directly to [redacted] and he accepted our resolution.  Due to the protected health information
involved, the details are not being given in this response. 
We
take customer complaints very seriously and appreciate you taking the time to
contact us and giving us the opportunity to address Mr. Khattak’s
concerns.  If there are any additional questions regarding this particular
matter, please contact the Executive Resolution Team at [redacted]@[redacted].com.
 
Regards,
Chris
B[redacted]
Complaints
and Appeals Consultant
Executive
Resolution Team

Dear Ms. [redacted]: Please see our response to complaint #[redacted] for [redacted] that was received by us on November 11, 2016.  Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you. In reviewing Coventry Health Care’s...

systems, we found that Mrs. [redacted] had a policy with us effective January 1, 2016.  The policy had been applied for through the Federal Health Insurance Marketplace (FHIM).  At the time we received the complaint, it was noted that the policy was active but had previously been terminated effective August 31, 2016, due to non-payment of the premium for September.  In regards to the statement that the policy was terminated and reinstatement was not allowed because of Mrs. and Mr. [redacted]’s health conditions, we wish to assure you that we do not use health conditions in making decisions regarding terminations and reinstatement.  The policy had been terminated in accordance with the FHIM’s premium payment guidelines.  Premium payments are due the last day of the month prior to the month of coverage being paid for, but the FHIM allows a 30 day grace period to make the payment before the policy can be terminated.   Coventry’s policy follows that guideline and allows the payments to be made up to 30 days from the date we send our past due notices.  The past due notice for September was sent September 8, 2016, so the due date was set as October 7, 2016.  Other month’s premium payments for Mrs. [redacted]’s policy had been made past the normal date the premium became due but were always within the 30 day grace period Mrs. [redacted] had been advised in error on October 25, 2016, that reinstatement could be granted if she made payment in full.  Unfortunately, the FHIM guidelines do not allow for reinstatement of policies that have been terminated due to non-payment, even with the misinformation she was given.  A check was received for the amount owed, but as the policy was still showing as terminated at that time the check was returned to her on November 8, 2016.   A reinstatement was granted due to a disaster declaration being issued for the county where Mrs. [redacted] lives.  Upon her county being added to the disaster declaration, the North Carolina Department of Insurance sent a bulletin to all insurance companies advising that standard premium due date policies and termination should be suspended.  The bulletin was dated November 3, 2016, and the policy was reinstated November 10, 2016.  The reinstatement is still in place and will be honored as long as the past due amount is paid.  If no additional payment is received, the policy will again be terminated back to August 31, 2016.  AT present the amount owed to pay through the end of November is $2094. We apologize for and regret any frustration or inconvenience Mrs. [redacted] has experienced during this issue.  We have contacted the appropriate area to provide feedback to the representative that advised her on October 25, 2016, that the policy could be reinstated if she paid the premiums in full.  Reinstatement was not something we were able to grant prior to the disaster declaration for her area. We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mrs. [redacted]’s concerns.  If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted].   Regards, Chris B[redacted] Complaints and Appeals Consultant Executive Resolution Team

[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the response. If no reason is received your complaint will be closed as Answered]
 Complaint: [redacted]
I am rejecting this response because:   When I call HII billing (whose # is on the back of the card), I'm directed to call [redacted] to speak with a claims broker for explanation of Benefits.  If [redacted] / Conventry, [redacted] is not assuming responsibility for this plan - then why is the the [redacted] logo on the card?  See attachments - the [redacted] logo is indeed on this card.    When I spoke to [redacted] - they denied any responsibility - and said that they would tell their customer complaint department regarding this grievance.  However - they are indeed involved in this scam - there logo is on an insurance card that was sold to me in this insurance fraud scam.  [redacted] also serves as the claims broker when I call to verify benefit services for this card.   It is [redacted]'s responsibility to help me collect a refund as they are part of the supply chain...  
Regards,
[redacted]

[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the response. If no reason is received your complaint will be closed Administratively Resolved]
 Complaint: [redacted]
I am rejecting this response because:I am rejecting this response because: AGAIN, I was mis-lead by a Coventry
Representor over the phone. I’m not exactly
sure what was heard over the recorded phone conference, but it appears to me
that their saying that I wasn’t Mis-Lead.. But I was!!!!
What I do Know is that ……… a Coventry representor told me that I would be
covered for a breast reduction at 100% as long as I had documentations, showing
that it was medically needed.  (ALL OF THAT INFORMATION WAS PROVIDED) And I
stand behind my word at 100%..... Again, I called a plastic surgeon by the name
of Dr. [redacted] only to find out that they didn’t cover Coventry
Insurance.  So that called lead me to
called my Insurance Rep. to see if they could further assist me.  Coventry, were very precise with their information
on what doctors would cover this procedures. 
They even informed me that they could either email or faxed me a list of
providers that were in-network……In which they did.  Once I got the list I found a surgeon and proceeded
with the process.   It really hurts badly,
to know that my insurance provider will not cover this medically needed
procedure.  I was informed that it had to
be a reconstruction issues, then later I was told that was not not a cover procedures at all….. It looks to me that Coventry can do and say
whatever they want to their customers, and pretend that they are doing all they
can do to satisfied us!!! (NOT)……it’s a shame that I can’t get any assistance
from my paid insurance provider.
I have appeal this twice, with not success and file a
formal complaint to the Revdex.com.  Hopeful my
information will help another customer.
My advice would be to have it in writing.  Because you will need to have a strong leg to
stand on, other than that we are out-numbered
Regards,
[redacted]

Dear
[redacted],
"Times New Roman"">Please
see our response to complaint #[redacted]
for [redacted] that was received by us on February 19,
Upon
receipt of the complaint, we reviewed [redacted]'s policy and found that a
request had been made to update her address on December 9, 2015. The new address she gave was outside of the
coverage area for the plan she had been enrolled on. Unfortunately, it was not immediately noticed
that the plan she was enrolled on was not offered where she now lives. The issue was eventually detected, which is
what generated the letter advising that policy was going to end as of March 31,
2016. We normally would only allow the
coverage to continue for days from the end of the month when the address was
changed. Since it was not caught
immediately, we instead allowed the coverage to remain active for days past
the end of the month in which we sent the letter.
We
also found that the payments were not collected in January and February due to
issues with the address update not being processed properly. That issue has been corrected and bills will
now be generated for the amount owed.
The plan is still active at present and there does not appear to have
been any disruption in the processing of [redacted]'s claims for
While
we are not able to extend [redacted]'s coverage under her current plan past
March 31, 2016, we do offer other plans in the area where she now lives. If she wishes to select one of the other
plans, a new application would need to be sent.
The plan change would take effect April 1, 2016, which means that she
would not have any lapse in coverage. We
have made several attempts to speak with her to discuss her options in
continuing coverage with Coventry but have been unsuccessful in reaching her.
We
take customer complaints very seriously and appreciate you taking the time to
contact us and giving us the opportunity to address [redacted]'s
concerns. If there are any additional questions regarding this particular
matter, please contact the Executive Resolution Team at [redacted].com
Regards,
Chris
B[redacted]
Complaints
and Appeals Consultant
Executive
Resolution Team

Dear [redacted]: Please see our response to complaint #[redacted] for [redacted] that was received by us on October 25, 2016.  Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you. Upon receipt of [redacted]’s complaint, we...

reviewed our Claims system as well as contacts that he had made to our Customer Service department.  It was found that [redacted] had been making payments to Dr. [redacted]’s office at the time of his visits, but claims for the services were not submitted to Coventry for processing.  Health Care Providers are able to collect amounts that they expect to be applied to a member’s deductible up-front, but claims then need to be filed in order for us to determine if any covered services should be applied to the in-network or out-of-network deductible and to apply any contractual agreements that we have with in-network providers.  At the time we received the complaint, a Customer Service rep had already begun working with the doctor’s office and their billing vendor, Doctor’s Professional Services Consultants, to have the claims submitted.  The claims were received November 1, 2016, and November 2, 2016.  Processing of the claims will be completed within the next 24 to 48 hours.  Once the processing is completed, we will send out an Explanations of Benefits showing the amount applied to [redacted]’s deductible and any amount left to be met.  If [redacted] paid more to the Dr. [redacted]’s office for a visit than we applied as his amount to the pay on the corresponding claim, Dr. [redacted]’s office would need to issue him a refund or credit on his account for the overage.  We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted]’s concerns.  If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted]@[redacted].com. Regards, Chris B[redacted] Complaints and Appeals Consultant Executive Resolution Team

Dear [redacted], Please see our response to complaint #[redacted] for [redacted] that was received by us on May 25, 2016. Upon receipt of [redacted] complaint, we reached out to the Customer Service department for the dental benefit plans offered by Coventry.  We were able to confirm that...

[redacted] had made contact with that department on August 14, 2014, and was advised that coverage for orthodontic services was limited to members of our policies who were under age 19 at the time treatment began.    Since [redacted] was above this age, her orthodontic services were not covered.  As further confirmation of the age limit for coverage, we have attached the policy document for [redacted]’s policy.  On the first page of the Schedule of the Benefits section of the document, this statement is provided regarding coverage for Orthodontic services: Orthodontic Maximum The total amount of benefits that will be paid over the total course of a lifetime is $1000 per Eligible Child under age 19 on the date orthodontic treatment begins.  We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted]’s concerns.  If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted]@[redacted].com.   Regards, Chris B[redacted] Complaints and Appeals Consultant Executive Resolution Team

[redacted]Please see our response to complaint [redacted] that was received by us on May 23, 2017.  Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.Upon receipt of the complaint, we found and...

reviewed the documentation previously submitted through Coventry’s online portal, My Online Services.  The documentation was then forwarded to our Claims department.  Work is ongoing to have the charges processed at this time.  Due to the complexity and length of the documents submitted, additional time is needed to finish the processing.  We expect the processing to be completed within 7 – 10 business days.  We apologize for and regret the delay.  Once processing is completed, a statement will be sent out with an explanation of our handling of the charges and a check for any eligible reimbursement.  We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] concerns.  If there are any additional questions regarding this particular matter, please contact the [redacted]
*Regards, Chris B[redacted]

------ Forwarded message ----------From: Revdex.com of Metro Washington DC <[email protected]>Date: Wed, Dec 30, 2015 at 11:40 AMSubject: Fwd: Complaint # [redacted]. Resolved ThanksTo: [redacted] <[redacted]@myRevdex.com.org>---------- Forwarded message ----------From: [redacted] <[redacted]>Date: Wed, Dec 30, 2015 at 11:31 AMSubject: Complaint # [redacted]. Resolved ThanksTo: "[email protected]" <[email protected]>[redacted]

Dear [redacted]: Please see our response to complaint #[redacted] for [redacted] that was received by us on January 26, 2018.  Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you. Upon receipt of the complaint, we...

reached out to our Medicare Grievance and Appeals unit.  We were advised that the issue was reviewed and it was found that [redacted] had contacted the area that handles the Healthy Rewards program in August and was advised that in order to review the incentive he would have to report the visit to them by the December 31, 2017.  It was also determined that the letters sent out regarding the program, subsequent to the initial post card, stated that he must report the required information within the eligibility period.  The eligible dates for the program in that letter are given as January 1, 2017, to December 31, 2017.  Since the notice was not provided until after January 1, 2018, the program had expired and [redacted] would not qualify for the reward.  We regret any frustration or inconvenience this issue has caused him.  We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted]’ concerns.  If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted]@[redacted].com. Regards, Chris B. Complaints and Appeals Consultant Executive Resolution Team

October 1, 2015Although I am definitely NOT happy with the resolution, because who knows if or when this "computer glitch" issue could happen again, I have decided that it is pointless to keep going around & around.  Thank you very much for looking into this issue for me!Sincerely,
[redacted]

Dear [redacted]:   Please see our response to complaint #[redacted] for [redacted] that was received by us on March 20, 2017.  Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.   Upon receipt of the complaint we reviewed the complaint again with our Billing and Enrollment department. The payments we received from the member totaled $373.90. She was issued a refund of $74.78 on or around July 2, 2016. The resulting net total of payments received is $299.12. The total owed for this time frame then is $299.12. As the amount paid is equal to the amount owed, no further refund is due.   Again we did note that the member stated her 1095 form only showed two months of coverage while Coventry’s systems show her having four months of active coverage. Her policy was applied for through the Federal Health Insurance Marketplace (FHIM). The 1095-A form is sent by the FHIM and shows the months of active coverage that the FHIM has on file. We reported the coverage dates for the member of January 1, 2016, to April 30, 2016, to the FHIM. If there is a discrepancy with the information shown on the form, corrections would need to be made by FHIM; Coventry is unable to update this information for the member. A review of the form can be requested by calling the Marketplace Call Center at ###-###-####. Please have the member call the Marketplace to have this information updated for her tax records. If the Marketplace updates any information on the member’s plan this will be sent to Coventry for updating; this includes both the tax form and the refund request.   We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted]’s concerns.  If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted]@[redacted].com.   Sincerely,   Ashley W. Complaint and Appeals Consultant Executive Resolution Team

-------- Forwarded message ----------From: Revdex.com of Metro Washington DC<[email protected]>Date: Mon, Feb 22, 2016 at 8:51 AMSubject: Fwd:To: [redacted]@myRevdex.com.org---------- Forwarded message ----------From: [redacted] <[redacted]@[redacted].com>Date: Sat, Feb 20, 2016 at 9:51 AMSubject: To: [email protected] is just a heartfelt and sincere vote of thanks for your help in solving my complaint, [redacted].[redacted]

[A default letter is provided here which indicates your acceptance of the business's response.  If you wish, you may update it before sending it.]
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution is satisfactory to me. 
Regards,
[redacted]

I have called in asking to cancel my insurance and was told I could not. My health insurance company is lying or did not update their records when I called. The fact of the matter remains that I have spent over 18 hours calling and fixing my health insurance. I have been lied to and forced to do a lot as a customer and have not been able to use my service for months due to misinformation. I need reimbursed for both my time and my health insurance premium as I have been being lied to and do not have any more time to fix what they have broken resulting in bills adding up that I should not have to pay because I have done my due diligence and beyond. Again I no longer have the time to do their job for them. I need to start seeing a discounted monthly premium (at least half) or reimbursed for the months I have asked to cancel my insurance and me being told I could not until "enrollment periods" as I was told. 
 Complaint: [redacted]
I am rejecting this response because:
Regards,
[redacted]

Dear [redacted],
Please see our response to complaint #[redacted] for [redacted] that was received by us on July 6, 2015.
During our review we were not able to locate a call from [redacted] where he requested to cancel his policy.  Termination requests can be made over the phone by...

calling our Billing and Enrollment department at [redacted].  I have also attached a termination form that can be filled out and faxed or mailed back to us.  The form lists the fax number and address for where to send it once completed. The plan will also terminate if premiums are not paid but we will not send a member to collections for unpaid premiums. 
We found that [redacted] had previously filed complaint [redacted] with the Revdex.com and was provided with a copy of the letter we sent in 2014 that advised of the plan change for 2015.  That letter contains a web address for the plan documentation.  We have attached a copy of the plan documentation and the renewal notice to this response as well.  He may also contact the Customer Service department at ###-###-#### if he has questions about benefits for specific services. 
A one-time exception was made during the previous complaint review to reprocess the claims that we had received for [redacted] up to that point and apply the benefits for his plan from 2014.  That process has been completed and he has been made aware of the new processing of the claims.  An exception will not be made to refund the premiums that have been paid for his policy. 
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted]’s concerns.  If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted]@[redacted].com.
 
Regards,
Chris B[redacted]
Executive Resolution Team

Dear
[redacted],
"Times New Roman"">Please
see our response to complaint #[redacted] for [redacted] that was received by us on April 5,
In
reviewing [redacted]'s complaint, it was noted that Trinessa is considered a
maintenance medication. We do allow two
fills of maintenance medications at retail pharmacies, but in order to have
additional fills covered on the plan, we require notification of the preference
to remain with the retail pharmacy. This
requirement is outlined in the attached Individual Member Contract. That document states:
Certain Prescription Drugs which are
prescribed for the treatment of long-term or chronic conditions are considered
to be Maintenance Drugs under the terms of this ContractIf you are prescribed
a Maintenance Drug, You may obtain the first prescription fill for a day
supply and one additional refill at a Participating Pharmacy that is a retail
pharmacyBefore receiving the third fill of the Maintenance Drug at the
Participating Pharmacy that is a retail pharmacy, You must notify us of whether
you want to use Your Mail Order Pharmacy benefit or continue to obtain your
Maintenance Drug at Participating Pharmacy that is a retail pharmacyIf You
fail to inform us of Your choice, then the third prescription fill (and any
subsequent refill of the Maintenance Drug) at a retail pharmacy will not be
CoveredYou may contact Us at any time to let Us know that You intent to use a
Participating Pharmacy that is a retail pharmacy for future fills of Your
Maintenance Drugs
It was
also noted that [redacted] does not intend to continue coverage with Coventry
due to now being covered by a plan through her employer effective April 1,
2016. Her plan is through the Federal
Health Insurance Marketplace so all termination requests must be made with the
Marketplace. At this time, we have not
received a communication from the Marketplace advising us to terminate her
policy. If we do not receive a
termination date from the Marketplace, the policy will remain active until the
end of June in accordance with the day grace period guideline established by
the Marketplace for members receiving an Advanced Premium Tax Credit. At the end of the grace period, the policy
will be terminated retroactively to the end of the month in which the grace
period began. In this case, if no other
premium payments are received, the termination date would then be April 30,
We
take customer complaints very seriously and appreciate you taking the time to
contact us and giving us the opportunity to address [redacted]'s
concerns. If there are any additional questions regarding this particular
matter, please contact the Executive Resolution Team at [redacted].com
Regards,
Chris
B[redacted]
Complaints
and Appeals Consultant

Dear
[redacted],
"Times New Roman"">Please
see our response to complaint #[redacted]
for [redacted] that was received by us on March 1,
Upon
receipt of [redacted]'s complaint, we reviewed her policy and found that the
procedure in question is specifically excluded from coverage. It was noted that first and second level
appeals have been performed asking for coverage for the procedure but the
decision to not allow coverage was upheld in both cases. The phone calls [redacted] had made to
Coventry were reviewed during the appeals processes and there were no instances
of misquoted benefits found
We
take customer complaints very seriously and appreciate you taking the time to
contact us and giving us the opportunity to address [redacted]'s
concerns. If there are any additional questions regarding this particular
matter, please contact the Executive Resolution Team at [redacted].com
Regards,
Chris
B[redacted]
Complaints
and Appeals Consultant
Executive
Resolution Team