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Consumers Have Rights When Dealing With HMOs

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CARY — In this day and age of managed health care, dealing with insurance claims can be a headache. For many people, the red tape can be overwhelming, especially when an HMO refuses to pay a bill.

But consumers do have rights, and oftentimes, if consumers fight back, they can win.

Rachel Gonzales will never forget Oct. 25, 1997. That is the day she fell down her stairs.

"I missed the first stair, and I completely tumbled all the way down," Gonzales explained.

"I found my daughter Rachel laying at the bottom of these stairs right in here. The first thing I did was cradle her head, and she said 'Dad, I can't breathe,'" said Gonzales' father, Harvey Yates.

When Rachel fell down the stairs head first, no one knew if she had broken bones or even a spinal cord injury, so the family called 911.

She was rushed to Western Wake Medical Center. Luckily she was okay. Her HMO, Healthsource, paid for the doctor and x-rays, but refused to pay her $200 emergency room bill. They told her that her case was not an emergency, and she should have called her doctor.

"I was not in a position to call my primary care physician, and my parents didn't have that information," Gonzales said. "They did the first thing they thought they needed to do."

The stateDepartment of Insuranceoversees insurance companies. Last year they received 347 complaints about managed care providers.

"If you don't think you're getting what you need, and if you don't think the plan is following the process, absolutely give us a call," said DeAnne Nelson of the Department of Insurance. "We'll do whatever we can to help."

For many consumers it's not the cost, but the principle.

"$200 dollars is not a large bill, but I don't think I should have to pay it," Gonzales said.

Monday afternoon, Healthsource reviewed the claim again and decided to pay it.

In January of this year, a new law went into effect which requires insurance companies to pay for emergency room visits when "an average person would consider the situation an emergency."

Healthsource points out that the law was not in effect when this claim was made. The company says it strictly adheres to the new law.

If you have concerns about your insurance company, you can call the state for help at1-800 546-5664.


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