Language Becoming an Issue for Health Insurers

[Harold F. Schiffman]

>>From the LA Times, 3/20/06

Language Becoming an Issue for Health Insurers
A Spanish-speaking couple is suing Blue Cross, saying it should not have
yanked a policy that it wrote in English.

By Lisa Girion, Times Staff Writer
March 20, 2006


When she learned the cost of an operation that opened her husband's
clogged arteries last fall, Maria Rodriguez was glad she had signed the
couple up for health coverage several weeks earlier. But then Blue Cross
of California said Raudel Rodriguez, a 53-year-old self-employed
scrap-metal hauler, had failed to disclose preexisting conditions
including chest pain that made him uninsurable. The company canceled his
coverage, returned $1,700 in premiums and left the couple instead with a
$130,000 hospital bill.  The Rodriguezes insist they answered the Blue
Cross salesman's questions honestly in a telephone conversation in
Spanish. If anything was amiss with the husband's application, they say,
the fault lies with Blue Cross because the company filled out their
applications in English, a language they do not understand. "What we want
is the deal they promised us if we paid them, we were covered," Maria said
in Spanish. Blue Cross, a unit of WellPoint Inc., declined to comment.

With a lawsuit accusing Blue Cross of reneging, the Santa Ana couple has
raised an issue that experts say could plague the health insurance
industry in coming years as it increasingly reaches out to cover
immigrants: Insurers could face legal problems unless they make sure they
are doing business with customers in a language they understand. The case
"could have a very dramatic impact in terms of elevating awareness on the
part of [health] plans to make sure that they are communicating in the
appropriate language with all their members and not just assuming
contracts in English are going to be understood," said Gerald Kominski, a
professor at the UCLA School of Public Health. Kominski is an author of a
new study that found that as many as 10% of HMO members in California
speak no English or have limited proficiency. "They pay their premiums,"
he said, "and they are entitled to the same level of service as
English-speaking members."

Under current law, however, non-English speakers have fewer safeguards
when buying health coverage than they do when buying a car or renting an
apartment. Auto dealers and other retailers that sell products with
financing long have been required to put contracts in Spanish if that is
the language used to make the deal, said Alejandra Cedillo, a Los Angeles
County Neighborhood Legal Services lawyer. That protection recently was
expanded to consumers who speak Asian languages. "There's nothing that
would apply to health insurance," she said. That's about to change. The
state Department of Managed Health Care expects to finalize rules this
year that would require health plans to put key documents in the
consumer's primary language and to pay for interpreters to accompany
patients to doctors' offices and hospitals.

For Maria Rodriguez, it was a Spanish-language television commercial that
prompted her call to Blue Cross last summer. She said she spoke to an
agent who described the plan and asked questions about the couple's
medical history all in Spanish. The couple said Raudel had complained of
chest pain early last year. But his physician had diagnosed heartburn, and
they had no reason to believe it was anything more significant.
Applications for coverage one for each of them arrived in the mail already
filled out in English, making it impossible for them to verify the
accuracy of the responses. The couple said they signed nonetheless. They
began paying premiums of more than $500 every other month on Raudel's
policy, which took effect Aug. 1. (The couple pays almost $500 every other
month on a separate policy for Maria, which remains in effect.)

A couple of weeks later, Raudel felt chest pain again and went to the
doctor. The physician ordered tests but found nothing wrong, the
Rodriguezes said. Finally, after the pains continued, a cardiologist
ordered a test that showed for the first time, the couple said, that he
had coronary problems.  The cardiologist told the couple that if Raudel
did not have surgery, he could have a heart attack. "I told my husband,
'Thank God we got that policy,' " Maria said. "We were scared [about the
operation]. But at least it was going to be covered." Raudel had the
operation in mid-September, spent three days in the hospital and went
home. A few days before Christmas, Blue Cross canceled their coverage
retroactively, citing information it had discovered in Raudel's medical
records.

The couple had no idea what the notification letter was about because it
was in English. It was not until Raudel went in for a follow-up visit with
his physician that they learned that he no longer was covered. "We cried
every day for more than a month," Maria said. Then they found a lawyer.
Jess Araujo, who practices in Santa Ana, contends that the case shows that
Blue Cross takes advantage of customers who cannot speak English. "They
want to speak Spanish to hook you in, but then they want to make sure they
put the contract in English," Araujo said. "Why do that? There's no
shortage of interpreters." Language is not the only problem in this case,
said Robert Gianelli, a Los Angeles lawyer who specializes in insurance
cases and is also representing the couple. He contends that Blue Cross is
using the benefit of hindsight to discern a pattern in Raudel's medical
record that his physician at the time did not. Moreover, he said, the
company examined the Rodriguez case with a microscope only to avoid paying
for expensive care an illegal practice known as "post-claims
underwriting."

Industry and legal experts say there is a fine line between improper
post-claims underwriting and responsible investigation of potential fraud.
"A prudent thing for an insurance company to do if it has a claim six
weeks after a policy goes into effect is to get the medical records from
the previous doctor to see if they got bagged," said Bob Laszewski, an
insurance industry consultant. "You'd be foolish not to ask for the
medical records." Laszewski said it would take more than a heartburn
diagnosis for a court to find a preexisting condition. "But if a guy had
been told he has angina or something of that sort, now it's a preexisting
condition," he said. "It's going to depend on what the facts and
circumstances are."

At the same time, said Bryan Liang, a physician and law professor at
California Western Law School in San Diego, "the insurance company had a
duty to investigate. If they didn't investigate ahead of time, that's
their problem." If the Rodriguezes lose, they said, to pay the hospital
bill they would have to sell the home in which they raised three children,
and Raudel might never get the follow-up care his doctors had ordered. As
it is, he buys his medications in Mexico, where they are about half the
price he would pay in Orange County. But he has not seen a doctor since
the couple discovered that Blue Cross dropped him. "We can't afford it,"
Maria said.

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