Thursday, June 11, 2009


The California Department of Insurance (CDI) announced that its enforcement action against PacifiCare Life and Health Insurance Co. is proceeding to administrative hearing.

Last year, Commissioner Steve Poizner filed an Accusation and Order to Show Cause against PacifiCare alleging thousands of violations of the California Insurance Code based on PacifiCare's failure to properly process claims from physicians, failure to meet its payment obligations on a timely basis, and a host of other improper claims paying practices. The alleged violations came on the heels of PacifiCare's acquisition by United Health Group, now the largest health insurance company in the United States. Since filing the Accusation, the Department of Insurance has continued to receive complaints from patients and providers about PacifiCare. A copy of the Accusation can be found by selecting this link.

The hearing is expected to begin later this year. It will be conducted before an Administrative Law Judge (ALJ), who will propose a decision to the Commissioner. Poizner will make the agency's final decision following receipt of the ALJ's recommendation.

The Department also has commenced a follow-up market conduct examination of PacifiCare. An initial market conduct examination that covered the period June 23, 2006 to May 31, 2007 disclosed thousands of violations that served as the basis of the Accusation. The Department's follow-up examination will, among other things, investigate PacifiCare's claims processing practices for the periods Jan. 1, 2006 through June 22, 2006 and June 1, 2007 through April 1, 2009.

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