Causey fines insurance company for numerous violations

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North Carolina Insurance Commissioner Mike Causey announced last week the state Department of Insurance has entered into a voluntary settlement agreement with Humana Insurance Company that includes a $630,000 penalty for numerous violations related to health insurance.

“Health insurance policyholders need to know what is covered and not covered under their policies,” Mr. Causey said in a Thursday release announcing the settlement. “I expect health insurers to do the right thing when it comes to paying claims.”

According to the NCDOI, the violations are related to policyholder treatment, claims practices, failure to notify providers of decisions in a timely manner and failure to use North Carolina-licensed medical doctors in the appeals process.

Included in the violations are the following items: subjecting members to out-of-network costs when in-network health care providers were not readily available, imposing cost-sharing for emergency services different from what would have been imposed with an in-network provider and failing to pay for emergency services in which a reasonable person would believe that a delay would be harmful.

In addition to the $630,000 penalty, which goes to the public schools as required by state law, Humana agreed to pay $227,205.94 to members at the request of the commissioner and the NCDOI.

According to the Insurance Business, Humana has accepted the voluntary settlement agreement without admitting any liability or violation of any federal or state laws, regulations or rules.

In addition to paying penalties and consumer payments, Humana has provided the NCDOI with a corrective action plan for the future.

Humana is no longer operating in North Carolina. It exited the small employer group health insurance market effective Dec. 31, 2014, and the individual major medical market effective Dec. 31, 2016.


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