|California Insurers Deny 21 Percent Of Claims,
Drawing State Probe
More than 1 of every 5 requests for medical claims
for insured patients, even when recommended by a patient’s
physician, is rejected by California’s largest private
insurers, according to data released by the California Nurses
Association/National Nurses Organizing Committee (CNA/NNOC).
Researchers analyzed data reported by the insurers
to the California Department of Managed Care and found that from 2002
through June 30, 2009, six of the largest insurers operating in
California rejected 47.7 million, or 22 percent, of all claims for
The findings have led to a statewide probe by
state Attorney General Edmund G. Brown, Jr. as to how insurers pay
"These high denial rates suggest a system that is
dysfunctional, and the public is entitled to know whether wrongful
business practices are involved," he said.
Brown’s deputies are pouring over HMO
records and conducting interviews with individuals knowledgeable about
HMO claims activities.
Leading the way in claims denials was PacifiCare,
40 percent in the first half of last year, followed by
CIGNA’s 33 percent. PacifiCare is in the middle of an
administrative law hearing to determine if it mishandled fees and
"The reality for patients today is a daily,
cold-hearted rejection of desperately needed medical care by the
nation’s biggest and wealthiest insurance companies simply
because they don’t want to pay for it," said Deborah Burger,
RN, CNA/NNOC co-president. "Every claim that is denied represents a
real patient enduring pain and suffering. Every denial has real,
sometimes fatal consequences."
Address: California Nurses Association/National
Nurses Organizing Committee, 2000 Franklin Street, Oakland, CA 94612;
(510) 273-2200, www.calnurses.org,