We take Kaiser Permanente to
the Maryland Insurance Administration

Continued from Part 1...

Dr. [name withheld to protect the innocent] informed us that with KP, we would have to go through a few times with unsuccessful IUI in order to qualify for IVF. All the attempts we had made in other countries weren't enough to prove to KP that we were good candidates for IVF. So the games continued, with time passing by.

Although no reproductive abnormalities had been noticed in either myself or my wife by any of the doctors in 4 countries, thanks to KP's delays, time had passed to the point that a hormonal test indicated not only IVF but also a donor egg. Dr. [name]'s insurance liaison called KP and was told that IVF was not covered at all if we use a donor egg. I would have expected that in a total of over 400 pages selling their program, KP would be able to explain any exclusions they may have. No exclusions like this are presented in the literature I had and both KP and the [employer] had informed me that no exclusions like this existed since no other literature pertained to reproductive medicine in our policy.

On January 26^th at 11:22AM I spoke with Katrina at extension 6264. We discussed IVF and asked why IVF would not be covered with a donor egg when I was informed that it would be covered. She checked my policy and said that she didn't know why someone had told Dr. [name]'s office that it wouldn't be covered. Since KP recorded the conversation, it will be on record that I mentioned donor egg at least 2 or 3 times. I requested that KP preserve this quality assurance recording.

At 15:20, I insisted with a customer service representative to speak with a supervisor. Reluctantly, she transferred me to Lena Flemming. Ms. Flemming read from a document which she later faxed to me. On page 8 of this document, (under "Infertility Exclusion(s)") it only excludes the retrieval of donor eggs. Although the wording of the title of this paragraph infers that it is a complete list of exclusions, page 3.10 states that any "procedures...that includes (sic) the use of donor eggs" are excluded.

By law, an insurance representative selling someone an individual medical policy must present the policy provisions before accepting payment for the policy. Why would this not be a legal requirement when one is signing up for a policy?

In these conversations, the KP employees referred to an "Evidence of Coverage" (EOC). I checked with Ms. [name] of the Benefits office and she again ascertained that she had not heard of such a document and KP had given them none, so they obviously had none to give me. (Finally on March 7, four months after beginning payment for the insurance, they provided me with the EOC. At this point, I was locked into this insurance policy because open enrollment wouldn't start for two more months, which is inadequate for us. This bait and switch tactic is unethical at best if not illegal.)

I then requested of Dr. [name] that he perform the IVF with my wife's eggs, KP had yet to present any exclusions from coverage for that. The physician told me that KP would not cover that either, but he promised to write a request to overturn the denial of authorization.

KP replied to that appeal on April 30, 2007. (See enclosure C.) They wrote, "We have overturned our initial denial and approved your request." We were ecstatic and called Dr. [name]. He was also interested in this ruling and called KP. They responded to him that the procedure approved was for IUI, a procedure for which we had approval for 3 months and was inadequate for us. One KP hand clearly didn't know what the other was doing. They approved something that wasn't requested and didn't respond to the request. More time was passing and fertility decreasing.

We appealed again and notified KP that we would take the case to the Insurance Commissioner if they continued denying benefits promised and paid for. On June 6, they responded, "We have thoroughly considered all of the available information related to your request... Your request was denied because your benefits...does (sic) not include coverage for donor egg services." Once again, they didn't address our appeal for permission to get coverage even for using my wife's own eggs. I wrote, "we request that you honor your initial commitment cover at least that portion of IVF that was initially promised."

Additionally, on or about February 22, 2007, I purchased several prescribed medications, using the KP pharmacy as they require. On December 9, the price I had paid for the Follistim 900U at Professional Pharmacy was $682.50 ($2047.50/3), retail with no insurance coverage. (See enclosure D.) The receipt for Follistim 900U from KP says "KP Price $3658.96" (for 4), "You Pay $1829.48". (See enclosure E.) Since I could get the same medication elsewhere for much less than $3659, I asked the pharmacy why the KP price was so high, as I'd much rather pay 50% of $682 per box than 50% of $915. They told me that I must buy from them, that the $1829 is not the 50% left after KP's copayment but that the 50% reimbursement would come from KP in the form of half the $1829 once I submit the paperwork. In March, I submitted all the paperwork they requested, requesting the 50% reimbursement they promised in the policy and orally. I have still not been reimbursed the $1534 of $3068 we paid. I wrote them on 4/27 and 5/29. I telephoned them on 5/29 and complained to Mitchel Alston on about 6/28 and 6/29 and he promised that they were faxing me a response "as we speak". To date, I have not received reimbursement or any response. I have requested an additional 1% monthly interest on their overdue payment.

In conclusion, my accusations of unethical and illegal practice are as follows: