Issued and entered November 22, 2002 by Frank M. Fitzgerald, Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On October 30, 2002, XXXXXXXXXXXX filed a request for external review with the Commissioner of Financial and Insurance Services (Commissioner) under MCL 550.1901 et seq., the Patient’s Right to Independent Review Act. The request was filed on behalf of Petitioner, XXXXXXXXXXXX. The Commissioner’s staff assessed the material submitted by the Petitioner and accepted the request.

The issue involved is contractual in nature and not a medical issue. Therefore, review by an Independent Review Organization (IRO) is not required. The Commissioner reviews contractual issues under MCL 550.1911(7). On November 6, 2002, the Office of Financial and Insurance Services received from US Health and Life Insurance Company (USHL) the information it used in making its adverse determination.

II
FACTUAL BACKGROUND

On October 10, 2000, Petitioner received services from Dr. XXXXXXXX, MD. Dr. XXXXX submitted the charges to PPOM, the third party claims administrator used by USHL, via their automated system. Neither PPOM nor USHL paid Dr. XXXXXX, which prompted Dr. XXXXXX to resubmit the claim to PPOM 90 days after original submission. Dr. XXXXXX resubmitted the claim every 30 days thereafter. On December 26, 2001, USHL denied payment because it received the claim after the 12-month filing deadline.

III
ISSUE

Whether US Health and Life Insurance Company complied with the terms of its Certificate of Insurance when it denied payment for services performed on October 10, 2000?

IV
ANALYSIS

Petitioner’s Argument

On October 10, 2000, Petitioner received services from Dr. XXXXXXXX MD. Dr. XXXXX stated his office staff submitted the claims to PPOM, the third party claims administrator used by USHL. He further stated he sent a follow-up claim to PPOM in January 2001, with no response. Additionally, every 30 days his accounting system prints a batch report noting outstanding accounts receivable. The system showed that neither PPOM nor USHL paid the claim. The system then automatically reprinted the claim and resubmitted it. Petitioner and Dr. XXXXXX argue they have submitted the claims according to the policy and believe payment is due for services received on October 10, 2000.

US Health and Life Insurance Company Argument

On August 29, 2002, USHL issued its final adverse determination. USHL upheld its denial for services rendered on October 10, 2000, alleging it received the claim after the filing deadline. USHL stated:

• On 12/26/01, USHL received a claim for services provided by Dr. XXXX on 10/10/00, through PPOM. Billed amount was $130.00. Re-priced amount (fee accepted by XXXXXXX Hospital) was $68.
• On 1/10/02, USHL sent an EOB to member and the doctor denying benefits because claim had been submitted untimely (more than one year after the date of service).

Under the Certificate of Coverage, the USHL policy states in part:

Proof of Loss Written notice of claim must be given to the Administrator within 20 days after the commencement of any claim covered by the Policy or as soon thereafter as is reasonably possibly.

Written proof of claim must be given to the Administrator within 12 months of the date in which the expense was incurred.

Payment of any claim will be made to the person rendering the services, unless you or your Dependent furnishes paid receipts with his proof of claim.

Failure to furnish such proof within the time required shall not invalidate nor reduce any claim if it shall be shown not to have been reasonably possible to furnish such proof within the required time and that proof was given as soon as was reasonably possible.

USHL believes it has properly applied the terms of the policy language when it denied payment of the services received on October 10, 2000.

Commissioner’s Review

The Commissioner reviewed the documents and arguments presented by the parties. The issue involved in this case is whether Dr. XXXXXX, submitted the claim for services according to the provisions of the policy. The policy language controls the analysis of this case. USHL policy language states written notice of claim must be given to the Administrator (PPOM) within 20 days after the commencement of any claim covered by the Policy or as soon thereafter as is reasonably possibly. It further requires the provider to submit written proof of claim to the Administrator within 12 months of the date of the services.

The evidence submitted by Petitioner demonstrates Dr. XXXXXX submitted to USHL a chronological listing of dates indicating resubmission of the claim. According to the policy language, Dr. XXXXX provided written notice on numerous occasions and therefore followed the provisions of the policy. As a result, USHL is required to provide payment for the services received on October 10, 2000.

V
ORDER

The Commissioner ORDERS that the final adverse determination of US Health and Life Insurance Company is reversed. USHL must pay for the services submitted by Dr. XXXXXXX in this matter. USHL shall pay for such services within sixty days of the date of this Order and shall provide Petitioner and the Commissioner notice of payment within seven days from the date of payment.

This is a final decision of an administrative agency. Under MCL 550.1915, any person aggrieved by this Order may seek judicial review no later than sixty days from the date of this Order in the Circuit Court for the county where the covered person resides or in the Circuit Court of Ingham County. A copy of the petition for judicial review should be sent to the Commissioner of the Office of Financial and Insurance Services, Health Plans Division, Post Office Box 30220, Lansing, MI 48909-7720.