Health Insurers Must Review Applications For Accuracy Before Issuing Policies, California Appeals Court Rules

Main Category: Health Insurance / Medical Insurance
Article Date: 03 Jan 2008 - 9:00 PDT

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A panel of the 4th District Court of Appeals in Santa Ana, Calif., last week ruled unanimously that health insurers are responsible for reviewing applications before issuing policies and should not wait until beneficiaries run up large medical bills, the Los Angeles Times reports. The court also ruled that insurers cannot rescind a health insurance policy unless they show that the policyholder willfully misrepresented his or her health or that the insurance company had investigated the application before issuing coverage.

In the case, Blue Shield of California is accused of inappropriately terminating an individual health insurance policy after authorizing more than $450,000 in medical services for a member. A lower court dismissed the case without a trial, but the appeals court overturned that decision and declared that insurers are obliged to verify information included in health insurance applications before extending coverage.

According to the decision, the facts of the case "raise the specter that Blue Shield does not immediately rescind health care contracts upon learning of potential grounds for rescission but waits until after the claims submitted under that contract exceed the monthly premiums being collected." The court ruled that a health plan "may not adopt a 'wait-and-see' attitude after learning of facts justifying rescission," adding that a company cannot continue to "collect premiums while keeping open its rescission option if the subscriber later experiences a serious accident or illness that generates large medical expenses." Blue Cross is considering an appeal of the decision.

The ruling sets the stage for similar cases against insurers to move forward in trial courts. Insurers and attorneys for policyholders say that courts previously have dismissed such lawsuits without trials, making it possible for health insurance companies to settle claims privately out of court (Girion, Los Angeles Times, 12/25/07).

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