Coventry Health Care, Inc.

Dear
Ms***,
Please see our response to complaint #*** for *** *** that was received by us on January 13,
During our review, we did find that the pre-existing condition exclusion was explained to Ms*** during a phone call she had placed to Coventry on January 21, 2014. We also noted that the certificate of coverage for Ms***’s policy outlines the pre-existing condition exclusion on page 10. I have included the relevant section below and have also attached the entire document to this response
There is no coverage for Covered Services to treat a Pre-existing Condition or Medical Conditions arising from a Pre-existing Condition until twelve (12) months has lapsed from the Member’s Enrollment DateThis Pre-existing Condition exclusionary period shall be reduced by the number of months for which you present proof of Creditable CoverageThis Pre-Existing Condition exclusionary period begins on the first day of the Waiting Period for Initial Enrollees or the Member’s Effective Date of coverage for Special and Annual EnrollmentsThis limitation also applies to any prescription drug that is prescribed in connection with a Pre-existing Condition
While Ms*** had sent a document to attempt to show that she had creditable coverage, it was determined that the previous plan she carried was a Discount Medical Plan Organization (DMPO). Unfortunately, a DMPO is not considered creditable coverage and can not be used to waive any part of the pre-existing condition period. Referrals from primary care physicians are also not able to be used to waive the pre-existing condition exclusion
The Affordable Care Act no longer allows insurance policies to contain pre-existing condition exclusion clauses as of January 1, 2014. However, plans already in effect on that date were allowed to keep the exclusions until their next contract renewal date. Ms***’s employer had begun their contract with Coventry on June 1, 2013. This means the clause would have continued to apply until June 1, 2014, if her coverage had not ended on February 28,
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms***’s concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at ***
Regards,
Chris B***
Executive Resolution Team

September 15, Dear *** ***:The Appeals Department of Coventry Health Care of Virginia, Inc(“Coventry Health Care”) writes this letter in response to the rejection of Coventry Health Care’s initial response of the complaint filed by *** *** regarding termination of her 09/01/policy and refund of her premium*** *** rejected the initial response because she has not received her refund of $from Coventry Health Care and that she is having difficulty working with the Marketplace to secure her refundThe policy slated to begin on 09/01/was successfully terminatedAs stated in the previous letter, Coventry is unable to process any changes to a policy that was initiated through the Marketplace per the Exchange rules and regulations that we as an insurance company must followOn 09/12/2014, a regional Health Insurance Marketplace Caseworker informed Coventry of the following:Regional offices [CMS] nor Issuers [Coventry Health Care] are involved in the appeals processOnce the consumer files an appeal with the Marketplace, the Marketplace will respond within days with next stepsThe appeals process and appeals determination is solely between the consumer and the MarketplaceThe determination on whether *** *** will receive a refund is processed through the MarketplaceThe Marketplace Appeals process is still ongoing in this caseNo further action is required or allowed by CoventryIf you have any questions, please contact the Customer Service Department at ***.Sincerely,Appeals Department

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and find that this resolution is satisfactory to me: Insurance cancellation for the end of October However, the business is still billing me for a November premium, and is trying to get late charges as I wouldn't pay a premium on a canceled policyTherefore, the business needs to accept that the policy has been canceled.
Regards,
*** ***

Coventry Health Care respectfully requests an extension of time to respond to the above-referenced Complaint
Thank you,
Deborah F*

[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 ***, and find that this resolution is satisfactory to me.
Regards,
*** ***

Dear ***
***,
Please see our response to complaint #*** for *** *** that was received by us on March 13,
The plan that *** *** had been covered by from his October 1, 2013, effective date until December 31, 2014, is no longer offered for any Coventry member. Due to this, we will not be able to change him back to that plan.
Our Customer Service department is currently reviewing the claims filed for *** *** to determine if reprocessing is needed. This review process was initiated due to *** *** speaking with a supervisor in that department, Emily D, on March 11, 2015. We respectfully request that he allow up to days for the review to be completed. He may follon the status of the review by calling ###-###-#### and referring to issue number ***. The review will factor in the plan change he experienced for and will include listening to the call that took place between *** *** and a Coventry Customer Service representative, Marilyn G, on January 30,
We were able to locate the section in the Certificate of Coverage (COC) for *** ***’s plan that allowed us to change the plan. The section is on page 13. We have included the entire COC as an attachment. The specific section provides this language:
Changes in Premium or Benefits
Premium rates are guaranteed for a period of twelve (12) months following Your initial Effective
Date or Renewal Date, as applicableAs appropriate, We may increase the premium or decrease
Covered Services for all Members covered under an Individual Contract in the event that any state or federal laws or regulation requires Us to cover additional services, reduce Coinsurance or Deductibles, or otherwise expand coverage in order to meet new minimum standards
In the event of an increase in premium or a decrease in Covered Services, We will send a notice to You via US Mail at Your last known addressAny such change will take effect upon the first
monthly renewal and upon approval from the North Carolina Department of Insurance, following the required notice period
We will notify You forty-five (45) days prior to a change in the premium
We will notify You sixty (60) days prior to any proposed decrease or increase in Covered Services,
which is not the result of law or regulation
We have also included a copy of the renewal notice that was sent to *** *** regarding the plan change. It was noted that the address on the letter is different than the address *** *** provided in the complaint. We were able to determine through documentation of a phone call to our Billing and Enrollment department that *** *** had moved and had not provided Coventry with the updated address prior to the letter being sent.
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address *** ***’s concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at ***
Regards,
Chris B***
Executive Resolution Team

September 15, 2014Dear *** ***:The member is participating in the Coventry Health and Life Insurance Company (“CHL”) HealthAmerica One individual HMO off exchange health benefit plan*** *** has filed a complaint with written consent on behalf of his son, *** *** (the “member”)The member’s complaint concerns premium refundsThe member’s father is requesting a refund for premium payments taken out of the member’s bank account after a request for termination of coverage was madeThe member’s father is requesting a refund for $362.00.Below is a timeline of events leading up to the resolution of the member’s complaintJune 5, 2014- *** ***/*** *** called stating that their son has been living in the state of Florida since April and is requesting a refund because his account was drafted in April through JuneThe member’s father requested a refund for May and June premium paymentsThe representative advised him to send in proof of coverageAugust 19, 2014- *** *** called stating that he has been trying to term this policy and we are still drafting from the accountThe CHL representative advised that the primary member must call in and request the terminationTyler came on the phone and requested to term the policyROOT CAUSE: The policy continued to draft from the account since the primary member never called or submitted a termination requestRESOLUTION: The policy is showing termed as of 08/31/since primary member (*** ***) called on 08/19/and requested to term policyPer business rules we termed the policy for the end of the month when the member sent in the request to termThe CHL representative advised if the member would like to retro terminate to receive a refund the member would need to submit proof of other coverage with effective date showingAt this time no refund is dueFurther, in Section 3- Termination of Coverage of the Coventry Health and Life Insurance Company Non-Employer Group Certificate of Insurance which states the following:
Termination: ATermination by SubscriberThe Subscriber may terminate Coverage for himself/herself and any enrolled Dependents under the Contract for any reason by providing thirty-one (31) days advance written notice to UsTermination will take effect on the first day of the month following the request notification periodThe notice of termination should be sent to:HealthAmericaOne TecPort Drive PO Box HarrisburgPA In the case of a termination in accordance with above paragraph of this section, the last day of coverage is:
-The termination date specified by the Subscriber, if the Subscriber provides fourteen (14) days notice;-Fourteen days after the termination is requested by the Subscriber, if the Subscriber provides less than fourteen (14) days notice; a date determined by the Subscriber’s QHP issuer, if the Subscriber’s QHP issuer is able to effectuate termination in fewer than fourteen (14) days and the enrollee requests an earlier termination effective date.-If the enrollee is newly eligible for Medicaid or MCHIP, the last day of coverage is the day before Medicaid or MCHIP coverage begins.If you have any questions or concerns regarding this matter I can be reached at ###-###-####.Sincerely,Emily MAppeals Coordinator

[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the responseIf no reason is received your complaint will be closed Administratively Resolved]
Complaint: ***
I am rejecting this response because:
1. Payment was sent in on 9/30/14, and is not the fault of the customer i.ethis writer, if the premium payment was not received until October 10, 2014. Customers should not be penalized for postal delays2. I did not receive the bill requesting payment in my mailbox until 9/29/14, though it was allegedly dated 9/18/14. I immediately sent in payment the following day. How was the premium payment to be received by the end of the month prior to the effective start date if the bill did not arrive until 9/29/14?
3. There is no explanation as to why the policy is not eligible for reinstatement.
4. Again, there is no satisfactory resolution to the fact that the letter sent to me stated that there had been multiple attempts to contact me for payment. One letter for premium payment does not qualify as "multiple attempts," especially since I immediately responded to said letter the following day with payment
Regards,
*** ***

[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the responseIf no reason is received your complaint will be closed Administratively Resolved]
Complaint: ***
I am rejecting this response because:Attached is the bank statement showing the late fee of $made 04/17/(days late), highlighted in green Please take care of this and I will accept the refund of $plus this $fee I look forward to finally getting this taken care of
Regards,
*** ***

Dear *** ***,
Please see our response below to the additional concerns reported in complaint #*** for *** *** that were received by us on December 8,
A formal authorization request for *** has not been received by Coventry. The authorization form that can be used to submit the request is attached to this response. The form must be completed and submitted by *** ***’s physician. Once received by Coventry, our Pharmacy Authorization department will review the request, make their decision, and send out notifications explaining their decision.
If the request is approved, an authorization will be entered in Coventry’s systems that will allow the claims for *** to be covered for a set period of time. The exact length of the approval would be explained in our notification letters. If the requested authorization is denied, the denial will be documented and the option of submitting an appeal will become available. Additional information regarding the appeal process would be provided in any denial notifications we send.
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address *** ***’s concerns. If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at ***
Regards,
Chris B***
Executive Resolution Team

Coventry Health Care respectfully requests an extension of time in which to complete its investigation into this Complaint

Dear
*** ***,
Please see our response to complaint #*** for *** *** that was received by us on January 30,
It was determined that the reason why *** *** has not received his policy information was because we did not have his full address on file. We were only able to locate one phone call made to our Billing and Enrollment department by *** *** on December 30, 2014. At that time, he was referred to the Marketplace to update his address, but an update was never received by Coventry.
While all address updates should be requested through the Marketplace and sent to us by them, we requested an exception in this case since the only part of the address missing was the house number. As adding the house number would not affect premium rates or exclude *** *** from the plan that he selected, the exception was granted. The address is currently in the process of being updated in Coventry’s systems
We respectfully request that *** *** allow us hours to complete the full address update process. Once the address update is finished, new plan documents will be ordered. The plan documents take 7-business days to be delivered after they are ordered. If he has questions about his plan prior to the documents being received, he can call the Coventry One Health Insurance Exchange Customer Service department at ###-###-####.
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address *** *** concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at ***
Regards,
*** ***
Executive Resolution Team

February 24, 2014Dear *** ***:I am writing in response to a complaint filed with your office dated 1/17/and received by our plan on 1/24/The complaint involves our member, *** *** and his wife, ***, who are currently enrolled in a Non-Grandfathered Individual
PPO plan (** ***) effective 12/31/to present.*** writes that he contacted Coventry on 12/18/looking for coverage to include maternity office visits and delivery of their second child, that he was told by the agent for Coventry that he could enroll in a plan and that it would include maternity coverageHowever, after his wife had maternity services performed in January 2014, she discovered that their insurance does not include coverage for her pregnancy.Based on ***'s complaint, we listened to the phone conversation *** had with our agent on 12/18/13, and it does appear that he called about several plans but was told by the agent that they could enroll in a plan to save money and that it would include maternity coverage.Because *** was misinformed about the coverage they ultimately enrolled in, we are willing to retroactively enroll them in a plan effective 1/1/that includes maternity coveragePer the enclosed documentation, there are two plan options available in his areaThey are both part of the Select Network and would cost either $(Bronze Standard Deductible Only HSA plan) or $(Bronze Standard $Copay plan) per month.*** and his wife can review the enclosed plan options and let us know if they would like to switch plans; if they want to switch, please advise *** *** at the Revdex.com who can then contact us, and we will re-enroll them in a different plan in our system.Of course, the ***s would also be required to retroactively pay the difference in monthly premium for January and FebruaryPlease note that the Select Network plans are limited network plans, so the ***s are encouraged to visit our website at:*** and use our interactive provider search tool to confirm that the providers they visit are in our network before switching plans.Should you require more information or have any questions, please feel free to contact me.Sincerely,

-------- Forwarded message ----------From: *** *** Date: Tue, Jul 15, at 11:AMSubject: Completed HIPAA Form - Complaint ID ***To: "***" ***:Please find attached the completed and signed HIPPA form.Thanks
*** ***Sent from my ***

Dear *** ***,
In order to investigate this complaint, we require the attached form to be completed and returned to us to confirm that *** *** is
authorized to act as a representitive for *** ***.
Sincerely,
Christopher B***
Executive Resolution Team

Dear
MsCameron,
Thank you for allowing us to address the concerns reported in complaint #*** for *** *** that was received by us on November 26, 2014, regarding issues with locating payments that she has made previously and the cancellation of the policy applied for through the Marketplace. Our Executive Resolution Team researched your concerns, and we would like to share the results of the review with you
The only payment that *** *** had made that we were able to locate that needed to be refunded to her was an EFT draft made on September 5, 2014, in the amount of $289.67. This was considered an unearned premium due to the termination of the non-Marketplace policy on August 31, 2014. That amount was refunded directly into her bank account with the number ending in *** on September 26, 2014.
If she feels additional amounts are still owed, further investigation will require bank statements supporting additional drafts or payments from her account. The statements sent previously showed the EFT draft from September 5, 2014, and the subsequent return of the same amount back into her bank account on September 26, 2014.
*** *** is eligible for a reinstatement of her Marketplace policy retroactively to September 1, 2014. Upon reinstatement, she will be responsible for making premium payments for the months of September through December. We have attempted to contact *** *** to determine if this is an agreeable resolution for her before proceeding with the reinstatement. At present, we have been unable to reach her but have left a message at the phone number we were provided. She may contact me directly at ###-###-#### with her decision
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address *** ***’s concerns. If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at ***
Regards,
Chris B***
Executive Resolution Team

Dear
*** ***,
Please see our response to complaint #*** for *** *** that was received by us on February 15,
It was noted that *** *** stated that he had actively acquired other health insurance that began January 1, 2015. His Coventry policy had passively renewed for 2015. In these situations we have been given the approval by the Centers for Medicare and Medicaid Services to terminate the passively renewed policy back to December 31, 2014. The termination process was completed on February 25,
We are not aware of any damage to *** ***’s credit rating by our attempts to collect the premium for the coverage for 2015. As the policy was paid through and it has been terminated back to December 31, 2014, *** *** no longer owes any money to Coventry for premiums. We were able to remove the $NSF fee that was applied when the payment we collected on December 31, 2014, was returned due to *** *** revoking the authorization for the draft with his bank.
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address *** ***’s concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at ***
Regards,
Chris B***
Executive Resolution Team

Complaint: ***
I am rejecting this response because:
We signed up with Coventry One through the Marketplace in December of 2013; however, we paid them our premiums but never actually had any coverageAfter carefully evaluating different health plans via The Marketplaces (www.healtcare.gov), I chose to sign up for a plan that was offered through Coventry OneI received a letter in December from Coventry verifying that my coverage would begin January 1st, and that my monthly premiums would be $257.58, which would be automatically withdrawn on the last day of each monthThen on May 28th, 2014, I received a letter in the mail from Coventry stating that "The Coventry plan you selected is not available in your areaThe plan should not have been displayed as an option for your zip code." As you can imagine, I was very upset to learn that I did not really have health insurance, but had been paying Coventry my monthly premiums all these months assuming that everything was fine and I was insuredEven after receiving this letter, Coventry took $from my bank account at the end of May and at the end of June.I had to go to my bank and pay a fee to ensure that Coventry would not be able to take any more money from my bank accountAfter speaking with numerous Coventry One representatives and spending countless hours on the phone, I have made no progress in securing a refund for the seven months of premiums that I paid to Coventry OneFurthermore, they told me on the phone that if I had incurred any medical expenses these last months, that they would NOT have paid them because I don't have any coverage through themThankfully, I have not had any medical expenses, but I do want my premiums back because I have been paying them for a service that clearly was not available in my areaToday I spent two hours on the phone listening to a Coventry One Representative named Billy Pgo back and forth with a Marketplace representativeFinally, we were able to speak with a Market place supervisor named Linna who confirmed that on the Marketplace system I was enrolled in the Coventry Plan on 12/23/and the coverage ended 1/1/This conversation was recorded and proves that I have paid for a service that I never actually hadCoventry One says that they are waiting for a retro-termination letter from the Marketplace before they will issue a refundI'm extremely weary of fighting this back and forth battle between the Marketplace and Coventry and just want my money backWhile I did sign up through the Marketplace for my health insurance, Coventry One clearly took my money each month, NOT the MarketplaceThis is part of the reason why I don't understand why the Marketplace is being so difficult to work withWe had a three-way call back in October where the Marketplace said they would send a request for a retro-termination letter and they would call us within days to let us know, but we never heard one word back from themTO further complicate things, we cannot even call the Marketplace and talk to someone in the escalation department because that is not allowed!!!
I want a refund for the seven months of premiums I paid to Coventry One for a total of $1,
Regards,
*** ***

Dear ***
***,
Please see our response to complaint #*** for *** *** that was received by us on April 21,
During our review, it was determined that *** ***’s policy was originally terminated effective December 31, 2014, because we are no longer offering service in Delaware CountyHowever, Coventry approved an exception for those members who didn’t receive the termination letter*** *** was one of those members, so on February 16, 2015, the policy was reinstated and an outbound call was made advising *** *** that his policy was reinstated and that he would have to make a premium payment for March and April to keep his policy activeHowever, as *** *** has requested, his policy has now been terminated effective December 31,
I apologize for any difficulties or confusion this may have caused *** ***We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address *** ***’s concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at ***
Regards,
Julian C***
Executive Resolution Team

Dear ***
***,
Thank you for allowing us to address the concerns reported in complaint #*** from *** *** that was received by us on November 10, 2014, regarding a premium payment not being received before the due date. Our Executive Resolution Team researched your concerns and we would like to share the results of the review with you.
We reached out to our Enrollment department for assistance during our investigationOur records show that we did not receive a premium payment until October 15, 2014. The premium payment needed to be received by the end of the month prior to the effective date, so the due date was September 30, 2014. Since the premium was not received by that date, the enrollment was cancelled. A letter was sent on October 9, 2014, advising them that the enrollment could not be completed and that they did not have coverage through Coventry. The payment we did receive was returned to the member on November 3, Unfortunately, the policy is not eligible for reinstatement
The complainant had requested additional reimbursement for a doctor’s office visit and a fine be imposed. As the premium was not received by the due date listed on the letters sent out, no further reimbursements will be made or fines paid at this time. Due to the letters not being received until late in the month, there was a shortened timeframe for sending in the premium, but the options to pay online, over the phone, or by overnighting a check through the mail were available in order to ensure the payment was received by the due date
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address *** ***’s concerns. If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at ***
Regards,
Chris B***
Executive Resolution Team