Complaint filed against TakeCare Insurance
by Mindy Aguon
Guam - While TakeCare is waiting on the Guam Memorial Hospital's Board of Trustees to decide whether its 30,000 members will still be covered at GMH, the insurance provider is now accused of deceptive practices as a complaint has been filed with the Banking and Insurance Board. In addition to a civil complaint filed late last year in the District Court against TakeCare Insurance Company, the attorney for Ina Gill has filed an administrative complaint against the company, alleging the insurance provider has misleading policy provisions that deceive Medicare recipients about their actual coverage to minimize its reimbursement costs.
TakeCare Insurance is accused of denying coverage to Peter Gill, who had traveled to the Philippines in 2009 for emergency medical treatment. According to court documents filed in Ina Gill's lawsuit against the insurance company, the couple had purchased a health insurance policy from TakeCare. In February and March of 2009, claims for coverage were presented to the company but were denied because Peter was covered by a Medicare health insurance policy and because he had sought emergency medical treatment in the Philippines. Peter passed away n 2009.
Attorney Curtis Van De Veld, who represents Ina, claims TakeCare denied Peter Gill coverage for medical costs and other costs covered by the terms of his plan and took steps to deny him coverage by invalidating his plan even though he knew he was entitled to coverage. He also alleges that TakeCare provided Ina with a false impression that they would fully and fairly investigate her claims for reimbursement and they did so allegedly to delay and frustrate efforts to take any legal action against the company for willfully failing to provide coverage to her husband under the plan.
The complaint also alleges that TakeCare has made unreasonable misrepresentations to its members by refusing medical reimbursement to its insured that are also covered under Medicare for medical costs incurred in the Philippines and discriminating against Medicare-covered plan members.
Ina Gill is seeking a judgment ordering TakeCare to pay the benefits and reimbursements due to her as well as attorney's fees. In the meantime, she's asking the Banking and Insurance Board to review her allegations of deceptive practices and police the insurance company's actions as they allege TakeCare promises to coordinate Medicare coverage for its insured and promises emergency coverage for its members. Attorney Van De Veld told the Banking and Insurance Board that TakeCare does neither and engages in this practice to minimize its reimbursement costs.
As for the lawsuit filed in the District Court, an amended complaint must be filed by next month with the trial set for October 30.
Banking and Insurance Commissioner Art Ilagan says administrative complaints such as these are first reviewed and if the allegations are substantiated, efforts will be made to settle the matter between the two parties and if that doesn't work, then the matter will be presented to the board. KUAM News contacted TakeCare for comment and they asked us to forward them a copy of the administrative complaint, but have yet to respond.
Meanwhile, TakeCare continues negotiations with the Guam Memorial Hospital as it seeks to have a direct payer agreement reinstated before next week.