No Intent Can Be Implied– though, to be honest, the intent is pretty clear

We are sometimes reminded, often by lawyers for people doing bad things, that we cannot infer legal intent from a mere course of conduct, no matter how consistent or seemingly suggestive.   This lawyerly principle applies even when that intent is expressed in a clear, polite, unambiguous “fuck you, asshole.”  

I’ve had my health insurance cancelled without warning twice since January 2020; luckily for me I found out about it the second time (cancelled without notice March 31) just in time to have my low-cost insurance back, as of May 1.  Nobody is to blame for any of this except, presumably, me, though intent on my part remains unclear.  

In January, when I called to pay my insurance premium for the ACA health coverage I’ve had for several years, the insurer told me I’d missed a ten-day “grace period” they’d had no obligation to inform me of and that my insurance had been irrevocably cancelled, pursuant to the “guidelines” (whatever those might be).   Two days later Healthirst, the insurer, confirmed that I’d lost an internal appeal and that my insurance had been properly terminated.

Meanwhile, I found an on-line consumer complaint form at the New York State Department of Financial Services, the agency responsible, among other diverse duties, for regulating health insurance companies that do business in the state.   Within two business days of submitting this complaint I had a call from Healthfirst, apologizing for its mistake and restoring my health insurance.

I was naturally curious about what law or regulation had caused them to reconsider their irrevocable, unappealable, legal decision.  They could not tell me. I want to know this law.  I’d like to publicize it to the many agencies I’d spoken to, government agencies who had no idea what the patient protection law in New York State requires of insurers before they can terminate ACA insurance without notice. Hearing nothing back from the Department of Financial Services, after my complaint quickly resolved my sudden lack of insurance,  I wrote them this:

I had a call from Healthfirst on January 28 informing me that their termination of my insurance had been a “mistake” and that they were sorry.  They admitted they had received my 1/24 NYSDFS complaint and were ready to accept the payment for January-June 2020 I’d attempted to make on January 22 when they informed me that I had no health insurance and that there was no further appeal at Healthfirst, or anywhere else.

I am wondering why:

1) there is no notice requirement before a health insurance company can terminate health insurance.  (I had absolutely no notice of the “ten day grace period” they suddenly waived after my DFS complaint);

2) NYSOH Marketplace, sole provider of ACA health plans in NYS, does not inform consumers of the practice of insurance companies abruptly (and “mistakenly”) terminating insurance for failure to pay during a “grace period” nobody is informed of;

3) there is no findable provision in the Patient Protection and Affordable Care Act, or NYS law, that sets out notice required before terminating policies.  

Is there no provision requiring private health insurance companies to direct suddenly insurance-free patients to the new NYSDFS on-line complaint process that can force immediate compliance with the unknowable law?

Is there someone I can talk to at DFS for more information about these questions?

Two weeks later, on Valentine’s Day, in fact, I had a response from DFS [1], a form letter, addressed to me, instructing me that DFS has no jurisdiction over my low-income healthcare and that all future correspondence should be addressed to the overwhelmed NYS Department of Health, the agency that oversees all Medicaid and Medicaid-like health plans for low-income New Yorkers.   The NYS Department of Health, perhaps because its programs serve primarily poor people with no other options, has no analogous on-line process for quickly resolving violations of undiscoverable laws.

My individual story had a quick reversal of fortune, a lucky, happy ending.   I did not lose my insurance for more than a few days, and it had been retroactively restored with alarming speed.   That was the position of the attorney at DFS who was assigned to provide me a copy of the law that had caused Healthfirst to reconsider its unappealable termination of my insurance.   He e-mailed me that since the insurer had admitted its error and restored my insurance that I should no longer need to see the provision of the law that had forced them to do so.

I periodically wrote to this lawyer for status updates, since he’d been assigned to provide me the relevant legal provisions I’d requested.   He asked me again, only six weeks in, to be patient, and questioned my stubborn-seeming need to know the law, since my insurance had been restored.  He also disputed my assumption that I’d not been alone in having my low-cost insurance abruptly terminated.  

He didn’t necessarily agree that a private company, with every incentive to cull non-profitable low-income insured from its rolls, and no disincentive, outside of being forced to admit error, if one of the poor devils stumbled on a legal remedy at the agency that regulates them; none of that meant that private insurance corporations would necessarily take advantage of unsophisticated or language-challenged low-income customers it was forced to insure by the opaque 906 page Patient Protection and Affordable Care Act.

It became a kind of hobby of mine, trying to remain polite to this government attorney, who seemed to be a kind of troll, judging by his terse non-responsive responses.   I was probably being unfair to the man.  He was probably right; I should have simply been grateful instead of a persistent burden to this hardworking government lawyer.

All was well, until, suddenly, in the midst of the worldwide pandemic, where I found myself at its epicenter, a doctor’s office I had an upcoming kidney disease-related appointment with (by phone) informed me that my insurance came up “inactive”.  I told them that was a mistake, my premiums were paid through June.  They told me I’d have to straighten this out with my insurer.   

It could not be straightened out with my insurer, who informed me that unfortunately there was nothing they could do — they were following orders from a New York State agency that they were forbidden, by law, to contact on my behalf.   I was told on that April 10 call that the insurer had been informed, electronically on March 11, to cancel my insurance effective March 31.   I’d had no such notice. Nobody, apparently, had any legal duty to inform me that I was about to lose my insurance or even that I was now uninsured.  During a pandemic.

I did not react well to this news.   In spite of the personalized February 14 warning that I was not entitled to use the DFS on-line complaint form (a warning not made anywhere on-line when you go to complain) I immediately submitted this:

I was informed Friday afternoon, when I called my insurer after being told by a doctor that my insurance came up “inactive,” that my Healthfirst health insurance, prepaid through June, had been cancelled, effective March 31 by the New York State of Health Marketplace.  

According to Healthfirst, no reason for this termination was given by NYSOH, NYSOH, I was told, had sent Healthfirst notice of their intent to terminate my ACA insurance on March 11.  Neither Healthfirst nor NYSOH provided me any notice of this termination, not prior to the effective date nor since.

I am instructed to call NYSOH, an overwhelmed and unresponsive agency on a good day, where one hears this recording:

New York State of Health is experiencing high call volume.  Because of the public health emergency we are extending the due date for people who are expected to renew before April 15.   You will receive another notice of the new due date before any changes will be made to your coverage.   You do not need to take any action at this time.  

Also, because of a new federal law, no person who currently has Medicaid coverage will lose their coverage during this emergency.  If you are enrolled in Medicaid and get a notice from New York State of Health telling you that your coverage will end after March 18, 2020, you can disregard this notice.  You will have no gap in coverage.  If you have Medicaid you do not need to report any changes to your account except a permanent address change.

I have to assume that termination of prepaid health insurance without notice violates some NYS law, administrative rule or something, in addition to the due process protection of the US Constitution and the PPACA.  One searches for New York’s legal answer to this question in Titles 10 (Health) and 11 (Insurance) of the NYCRR  in vain, there is no chapter on point.  

Can you help me get my improperly terminated insurance back during this worldwide plague? I’d be eternally grateful.

 

Thankfully, before they had time to act on this complaint, a friend helped me discover a copy of the March 11 “notice” from the NYSOH, on their website, in my inbox.  I’d received no email informing me of its existence on the website low-income New Yorkers are required to visit annually to re-enroll, not that day (when I could have acted to save my insurance for April), not any day.   I also did not receive a copy of this notice by mail, not in March, not on any day.   When my friend asked if I’d checked the website, and my “inbox”, I went on-line, saw the “notice” for the first time, fixed the omission in my application, re-enrolled and was quickly good to go effective only a few weeks later, on May 1.

I attempted twice to retract my DFS complaint, on April 14 and April 15.  I wrote:

I withdraw complaint CSB-2020-01351366.  Healthfirst had nothing to do with this termination of my ACA health insurance. They might have informed me of the impending loss of my insurance, which they knew of for three weeks before it was terminated, although they likely had no legal duty to do so and every business reason not to.  My complaint should not go to Healthfirst.

My insurance was terminated by the NYSOH, for my own oversight,which remained uncorrected for lack of notice of the mistake by NYSOH.  I have since been able to correct this oversight and my insurance will be restored effective 5/1/20.  

Please terminate this complaint. 

I was too late, though, the wheels of justice were already grinding on my behalf. The very next day I had a call from the same Resolution Specialist at Healthfirst who’d resolved nothing previously, informing me in grim tones that they had received the DFS complaint, that she was calling pursuant to it and so forth.   My description of that unexpectedly pleasant chat is here.

Here’s the thing, though.   Within a couple of days, on April 17, I had an email from DFS with two attachments.  The first attachment was the same form letter I’d received previously, directing me, as a low-income New Yorker, to the Department of Health, informing me, again, that, although they’d once again quickly investigated my complaint, DFS was not the proper agency to contact, since I was too poor to qualify for their on-line consumer services.  

The second attached PDF was an official summary of legal findings  — something we must note was not prepared or sent to me in the previous case, when the insurer had, and later admitted, erroneously terminated my health insurance in January.  

Again, no inference of intent is drawn, why should it be?   Can an agency or a corporation even have intent?   The report of their legal findings was dated April 16, 2020, the day after my second attempt to retract my complaint.

Curiously, on the cover sheet of this three page report, next to the box “Has the member been made whole?” the answer DFS inputted was NO.

I have transcribed it from the PDF faithfully (outside of a few added comments):

This communication serves as the Plan’s Response to the Member EW (sic), grievance against the Plan regarding his termination of coverage on 03/31/2020.  We have researched the member’s grievances and provided below is a summary of our findings and resolution.  

Upon receipt of the complaint the Enrollment and Billing Departments advised:  

* The Member EW enrolled into Healthfirst Essential Plan with an effective date of coverage for 01/01/20.   The Member’s coverage was active and paid through March 31, 2020 (paid through June 30, actually, but why quibble?).  

* On 04/15/20 the Enrollment and Billing Department advised (who?) that the Member’s coverage was terminated as per the New York State of Health transaction file no. ET00158341700 received on March 11th, 2020.   (Note, 4/15 was days after I complained of this conversation, which took place April 10)

* An inquiry was sent to the New York State of Health regarding the Member’s coverage termination.

The Plan advised (was advised?) that on:  

*On 12/07/2019, the New York State of Health sent a letter requesting proof of income that needed to be submitted by 03/05/20, in order to maintain continued coverage.  (why March 5, a deadline both arbitrary and capricious?)

* On 03/11/2020, the New York State of Health sent another letter indicating that proof of income was not received as requested, and that Member’s coverage will be terminated effective 03/31/2020.     (really)

* On 4/14/2020, the Member uploaded the required documents and was re-enrolled for an effective date of coverage 05/01/2020.  

* On 04/16/2020, the Member Services Department outreached the  Member regarding his complaint.   The Member informed the Plan that he realized that the termination was not Healthfirst’s decision, but on the part of the New York State of Health.   The Member advised that he tried to rescind the complaint but realized it was too late (he did when he got the call from insurer– for sure — ed.).  The Member verified that as per New York State of Health that his coverage would begin 05/01/20. A credit is currently on file and will be applied to the Member (sic) future coverage (applied to July’s premium, actually).  

We trust that this response provides sufficient explanation for your inquiry.

The official report was signed by a female employee of DFS, to whom I can only say, (with Joe Biden-like insouciance), it could all not have been clearer, sweetheart.

 

 

[1]

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