The California Department of Managed Health Care ordered Kaiser Foundation Health Plan to immediately reinstate coverage for a member, a first in the state agency’s six-year history. In an order issued earlier this month and posted online Oct. 18, the department told Kaiser to "cover all charges for medically necessary treatment" for the woman, who has a congenital kidney disorder that causes severe kidney stones. The woman had been a Kaiser member from 1984 through September 2004, when Kaiser ended her coverage for failure to disclose arm and neck pain in a new application for coverage. The member said a Kaiser physician had diagnosed and treated the pain earlier and the plan had paid for her medication. The state ruled there was no evidence that the member intended to deceive Kaiser. The department hasn’t issued fines or penalties related to the termination. It continues to investigate allegations of allegedly illegal coverage terminations by several health plans. Earlier this week, Blue Cross of California agreed to settle more than 70 lawsuits and claims filed by former members who accused the insurer of illegally canceling their policies. Terms of the settlements weren’t disclosed.
Kaiser spokesman Matthew Schiffgens said the member now is receiving the treatment she needs. "We have made significant enhancements in how we handle disputes about membership applications since 2004 when this case occurred," Schiffgens said. "The issues raised by the DMHC in this case will be reviewed carefully to see if there are additional modifications we should make."