Buying an insurance policy may seem like a complex and detailed matter. There are a lot of things to consider when figuring out which plan will work best for you. This can mean determining what your budget is or looking to see what health care providers you may receive access to. Of course, people go through this process to ensure that they pick a plan that works best for them, and one that ensures that they will be covered for any future incidents or health issues. Also, when making this decision, people will look at different insurance companies to see which one will provide the best benefits. All of this is to make sure that they work with an insurance company that will work for them and will follow through with their promises.

However, there are cases in which insurance companies do not follow through on their promises. Unfortunately, it is a common occurrence for companies to shortchange their customers when working with them. This can include actions regarding false advertising and changing customers’ plans and benefits without their awareness. Recently, Blue Shield of California, a major insurance company, was faced with a lawsuit dealing with EPO members and improper practices. For customers who have faced issues under Blue Shield, Stop Health Insurance Denials is here to help you. With top-rated insurance lawyers, our top-notch team is well-experienced in dealing with situations where insurance companies have denied a customer’s claim. By contacting us, you can feel sure that you will be receiving some of the best help in the nation.

Differences Between PPO and EPO Plans

The Blue Shield EPO lawsuit stems from a critical differentiation between PPO and EPO plans. Most of the concerns that the company’s customers faced came from confusion and inaccuracy around what each type of plan entailed. Thus, it is crucial to understand what makes each type of plan different.

Blue Shield offers both an EPO plan and a PPO plan to its customers. An EPO (“exclusive provider organization”) plan is similar to an HMO plan in that it only covers a certain amount of the costs for visiting health care doctors and providers listed within its network. Also, with an EPO, customers are not covered for services received outside of the network. This would be that if they visited a doctor outside of the plan’s listed network, they would have to pay the full amount billed by the provider. Usually, an EPO network is more limited, meaning that customers can only visit certain doctors.

At the other end, a PPO plan usually has a more expansive list of doctors and care providers within its network. Also, customers under this plan may receive certain discounts for visiting these healthcare providers. On top of this, these customers may have certain coverage for going outside of the plan’s provider network to receive health care. This plan is more flexible, but it is often more expensive.

Because of the differentiation between the types of health care insurance plans, most customers take consideration when picking out a plan that works for them. Simply put:

  • EPO = a limited network of covered healthcare providers and no coverage for receiving services outside of this network.
  • PPO = a larger network of covered healthcare providers and some coverage for receiving services outside of this network.

 In the Blue Shield EPO lawsuit, a situation is described in which customers were left unsure of what plan they actually were on at the fault of the company; thus, causing issues for the customers.

Blue Shield EPO Lawsuit

In 2014, the insurance company, Blue Shield of California, was faced with a class action lawsuit. The case revolved around circumstances relating to benefits received and those not received under the company’s different insurance plans.

The lawsuit alleges that Blue Shield use various deceptive schemes that caused major issues for their members. More specifically, the suit claims that Blue Shield misled their customers to believe that their doctors and/or health care providers were included within their plans. Also, the networks in which the customers bought into were inadequate, interrupting and delaying any necessary medical services. The lawsuit also states that the company’s members faced delayed enrollment into their plans which also significantly affected their reception of proper health care services—even though they paid for the insurance. These customers also faced long wait times should they call to resolve their issues with their insurance. The three critical points are:

  • “Bait and switch” misrepresentation
  • Inadequate physician and hospital networks
  • Mishandled individuals’ health care plans

Earlier, in 2013, Blue Shield canceled its non-ACA (Affordable Care Act) compliant insurances and placed new, compliant ones in its place for the 2014 year. As stated in the claim, Blue Shield advertised these new plans as having the same providers as their original plans. Thus, if the members were on an EPO plan or a PPO plan, they believed that they would receive the same, or similar, benefits and networks as before. However, once these members were enrolled in the new 2014 plans, they soon found out that their plans did not include the same providers as before, as advertised. Thus, the customers did not receive the benefits they were promised from their insurance company. By not disclosing the differences in network limitations, Blue Shield was able to increase their sales.

Secondly, some members who paid for specific plans did not receive valid proof of the insurance in the form of a membership card within a reasonable amount of time. Because of this, these members were unable to receive their proper medical services, or they were forced to pay for the services out of pocket. This with the added confusion of the networks included in the plans, customers would call Blue Shield only to wait a long time to receive assistance.

All of these issues led to unwarranted claim denials by Blue Shield. Without the proper marketing and without abiding by the proper protocols, Blue Shield broke its promises to its customers. The lawsuit alleges that the insurance company is in violation of multiple different federal and California state laws.

Bad Faith Practices

The lawsuit against Blue Shield alleges that the company participated in illegal activities or activities that may be considered to be done in bad faith. Usually, bad faith practice includes ones in which an individual's claim is unjustly or unfairly denied or delayed in any way. As stated within the lawsuit itself, it claims that Blue Shield used bad faith practices, such as misrepresentation, making customers wait unreasonable amounts of time to receive assistance, mishandling their customers’ plans, and more. Along with these actions, other bad faith actions may include:

  • Unjustly denying coverage
  • Not providing important information about coverage
  • Not investigating a customer’s claim
  • Not paying a claim without properly investigating
  • Not paying or denying claims within a reasonable set amount of time
  • Not providing a reasonable or lawful explanation for why a claim is denied
  • Not disclosing the policy’s, or plan’s, limits of benefit

These behaviors and more similar actions may be read as bad faith on the part of the insurance company. This simply means that the company is not backing its promises with regard to customers’ plans in any way. For victims of the Blue Shield case, they faced unfortunate consequences from some of the company’s mishandlings and errors. As commonly asserted with similar cases involving insurance, insurance companies have a duty of good faith and fair dealing when it comes to their customers. Most of the time, bad faith practices include not properly investigating a customer’s claim. Under the Blue Shield lawsuit, the company’s customers did not receive fair treatment when it came to submitting their claims, for they did not receive the right information and the company refused to accept claims that were made in error based on their mistakes.

Below are some specific issues and violations describe within the Blue Shield lawsuit which may also apply to other issues with insurance companies.

Not Providing Important Information

The Blue Shield lawsuit mainly revolves around Blue Shield’s actions regarding not properly advertising or informing their customers about the new plans that they were receiving. The customers felt that the company used fraudulent and deceptive methods in order to generate profits. Also, the customers alleged that Blue Shield did not display accurate lists of network healthcare providers during its Open Enrollment Period. Not only did the company inaccurately provide important information about their plans, but they also failed to accurately disclose information about the plans’ limits and benefits. These actions are in violation of certain laws, such as Civil Code § 1770.

Thus, when customers were incorrectly informed that their EPO plans retained a similar list of healthcare providers as before, they naturally purchased it since it was the cheaper option. Yet, in the end, these customers would face future health insurance denials as a result of the false and inaccurate information provided by the company.

Long Wait Times

Even though it may seem like a menial thing, wait times can be a crucial factor, especially in situations pertaining to your health. Under the Blue Shield lawsuit, there are multiple situations described in which customers waited hours to receive assistance or none at all. This is a problem. Under California’s Code of Regulations § 1300.67.2.2(c)(10), an insurance company cannot make its clients wait more than ten (10) minutes when receiving help. By purchasing health insurance, you buy into the idea that someone will be there to help you when you need it, especially if it’s a medical emergency.

Insurance Denials

The larger issue stemming from Blue Shield’s misrepresentations and confusion during this period is insurance denial. As stated in the above sections, Blue Shield’s customers faced many different issues regarding their plans during the enrollment period and after the enrollment period. As a result of the inaccuracies provided during this period, many customers were led to believe that the plans they were purchasing or going to purchase did have the same networks and benefits that they had before. More than this, Blue Shield continuously provided inaccurate information that misrepresented what their plans entailed.

Because of these inaccuracies, many customers would then be denied when they went to visit a doctor, or any other healthcare provider, listed under the false network lists. Even though some of the customers actually contacted the company and they consulted the website to ask about who is and is not provided within their networks, they would still receive wrong information.

Despite the misinformation that Blue Shield put out to its customers, they would still deny their claims. This meaning, that the company would not pay for their customers’ medical expenses, because, in this case, the providers were not actually in their networks. Through this, the company would save money since they would not have to pay for claims under this technicality. This is a violation of these customers’ rights as policyholders.

The Rights of the Policyholder

If you do have an insurance policy with any insurance company, then it is crucial to know that you do have rights. Also, in certain states, there may be laws regarding your rights as an insurance policyholder. These laws and more are put in place to ensure that you receive the service that you have purchased and to make sure that insurance companies do not take advantage of you. Of course, specific laws and details may vary depending on what state you live in. However, in most cases, when you do buy an insurance policy you have to sign a contract with the company, and within this contract is listed your rights as an insurance policyholder. If you do have a policy, then it may be beneficial to review those rights and terms when considering your situation.

Not all states and all insurance companies provide the same rights for policyholders. However, it would be beneficial to get an idea of what your rights may look like in a general sense. It is always an excellent idea to thoroughly research your rights. You may even seek the assistance of a skilled insurance lawyer to ensure that you receive the proper information regarding your rights. Besides this, a general idea of your rights may include:

  • All claims should be properly investigated, processed, and paid out within a reasonable amount of time and in good faith.
  • You should be treated fairly and equally by your insurance.
  • All details about your insurance policy and its benefits should be properly communicated.
  • Your insurance should not misrepresent any information pertaining to your insurance policy.
  • Insurance companies may not discriminate against their customers.
  • The insurance company has to respond to any questions or concerns you may have within a reasonable amount of time.
  • You should be notified of any important deadlines regarding your insurance policy.

This is just a general notion of what your rights as a policyholder may entail. Each state and each insurance company may provide different rights to policyholders. Yet, generally, these are meant to provide protection to policyholders should they be taken advantage of by their insurance companies. If you feel that your insurance company has violated your rights, then you might be able to take your complaint to court. Like with the Blue Shield EPO lawsuit, customers have a right to be treated properly. If not, then they may be compensated or reimbursed under the eyes of the law for their mistreatment. With the assistance of a skilled insurance lawyer, you can fight any injustices that you may face.

Locating an Insurance Lawyer Near Me

For victims of the types of actions mentioned under the Blue Shield EPO lawsuit, there is help available. You should not have to suffer financially or health-wise from Blue Shield’s mistakes. Even though most insurance companies are run like any other type of business (this meaning that they seek to make profits), they still have a responsibility to treat their customers right. Since people put a lot of faith in their insurance companies and in their plans, it is vital that any type of insurance holds onto its promises. Due to the seriousness of the types of situations in which insurance is necessary, it must always be there for their customers without any loopholes or unforeseen issues.

Even though everyone would like an insurance company that treats them right and fulfills all of its duties, it is a sad truth that sometimes this does not happen. Customers are sometimes left to fend for themselves, so to speak. If your insurance provider has gone against your rights, used bad faith practices, or has denied your claim for an unjust reason, contact Stop Health Insurance Denials now. By calling our number, 310-695-5241, you can be sure that will be reaching some of the best insurance attorneys in the nation. Our staff is highly skilled and experienced in matters relating to insurance denials and unjust treatment by insurance companies. If your insurance company has not been there for you, we can be—and help you with every step along the way.