Texas Department of Insurance Complaint Form
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Consumer Protection (111-1A) |
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Required Fields |
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Date : |
December 22, 1999 |
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Insured or Claimant's Name : |
Ronald James Martin |
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Claimant's E-mail Address : |
rjamesmartin@yahoo.com |
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Address : |
501 Sycamore Lane, #327 |
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City/State/Zip Code : |
Euless, Texas 76039 |
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Phone (Work) : |
817.540.2272 |
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Phone (Home) : |
817.540.2272 |
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Policy Information |
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Policyholder's Name (if different from yours) : |
SAME |
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Address (if different from yours) : |
SAME |
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City/State/Zip Code (if different from yours) : |
SAME |
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Complaint is Against: Other (please specify) : |
THIRD PARTY ADMINISTRATOR |
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Type of Coverage: |
GROUP HEALTH |
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Date Loss Occurred or Began : |
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Name of Insurance Company : |
FIRST HEALTH STRATEGIES (TPA), Inc. |
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Group Policy No. : |
H2823 |
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Name of Employer (if Group Policy) : |
S & A Rest Corp/Metro Stkhs Co LP |
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Agent's Name : |
FIRST HEALTH STRATEGIES, Inc. |
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Agent's Phone No. (if known): |
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Agent's Address (if known) : |
P.O. Box 671088 |
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City/State/Zip Code : |
Houston, Texas 77267-1088 |
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My Complaint is: (Please describe and attach any documents that you believe are necessary in helping us to solve your complaint.) |
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My original complaint read:
--- Consumer_Protection@tdi.state.tx.us wrote:
Date: 28 Aug 99 16:38:35 GMT
From: Consumer_Protection@tdi.state.tx.us
Subject: Life Health Complaint Form
To: rjamesmartin@yahoo.com
Thank you very much for taking the time to fill out this form. As a reminder, you submitted the following data at Texas Insurance Consumer Complaint Form (Forma para una Queja) on: Saturday, August 28, 1999 at 11:38:35
Date: August 28, 1999
Claimants Name: Ronald James Martin
Claimants E-Mail: rjamesmartin@yahoo.com
Claimants Address: 501 Sycamore Lane, #327
Claimants City State Zip:Euless, Texas 76039
Claimants Work Phone: 817.540.2272
Claimants Home Phone: 817.540.2272
Policyholders Name If Not Yours:Same
Address If Not Yours: Same
City State Zip If Not Yours:Same
Complaint is Against: other
Other: Third Party Administrator
Type of Their Coverage: Health Health
Other Type of Coverage:
Date Loss Began: April 24, 1999
Name of Insurance Company: First Health
Individual Policy No.
Group Policy No. H2823
Certificate No.:
Name of Employer If Group: S & A Rest Corp/Metro Stkhs Co LP
Agent Name and Phone No. First Health
Agent Address: P.O. Box 671088
Agent City State Zip: Houston, Texas 77267-1088
Name of Other Person:
Name of Their Employer or Business:
Name of Their Insurance Co.:
Type of Their Coverage: Health Health
Their Policy or Claim No.:
Complaint Narrative:
1. I am aware that my company is an ERISA self-insured company.
2. My complaint is the bad-faith, unethical, fraudulent business practices of First Health, acting as the third party administrator of the company plan.
4. Following my "full, fair, and final" review of prior rejected claims by the company Named Fiduciary, in which some denials were overturned, and others upheld, First Health has not paid for any services. In my wife's case, there are pended claims dating back to 1995 that have not been properly processed. Until she became totally disabled, expired her COBRA, and First Health became primary carrier, this simply involves coordination of benefits with her previous primary. Despite letters from Sonja Driggers promising release and reprocessing, this has not happened.
5. All of my claims following the "full, fair, and final" review have been processed, with the action of "Please provide a copy of the patient's medical records". No reimbursement has been received.
6. A complete copy of the medical record was provided to complete the "full, fair, and final" review, with complete documentation provided for each subsequent doctor visit.
7. The doctor's office sent all records certified, return receipt requested, and maintains the receipt.
8. When queried by the doctor's staff, since the signature could not be deciphered, they maintain they don't have the records.
9. When the doctor's staff, with their interest being through assignment of benefits, queried the Named Fiduciary about assistance in breaking the log jam, was snidely told that I knew the appeal procedure, and he shouldn't be bothering her. She further stated that just because services had been paid for in the past didn't guarantee payment in the future.
10. In a prior complaint to you about First Health, I received a letter from a corporate attorney that basically said, being ERISA, go to Federal Court, can't do anything to us at the State level. It should be noted after sending this "protection" letter, they subsequently paid half of the bill that was complained about.
I understand that my company, being ERISA self-funded, can make up whatever benefit rules they want, even introduce erroneous facts into the Administrative Record if they feel like it. That is not the issue. The bad-faith, unethical, fraudulent business practices of First Health in stalling, lying, and plain sloppy mailroom practices, as Third Party Administrator is the issue.
I feel they must be called into account.
Thank you,
R. James Martin
501 Sycamore Lane, #327
Euless Texas 76039
817.540.2272
https://www.angelfire.com/biz/romarkaraoke/james.html
Fair Resolution:
1. Adopt ethical business procedures.
2. Reprocess all denied or pended claims in an ethical manner.
3. Introduce accountability in their mailroom, i.e. properly log all certified, receipted mail.
4. Introduce accountability in their routing from mailroom to computer data entry, i.e. signature routing forms.
5. PAY THE DOCTOR IN A TIMELY MANNER.
6. Compensate the doctor for unreasonable efforts, i.e. pay for multiple copies, multiple mailings.
I feel they must be called into account.
Thank you,
R. James Martin
501 Sycamore Lane, #327
Euless Texas 76039
817.540.2272
R. James Martin
rjamesmartin@yahoo.com
https://www.angelfire.com/biz/romarkaraoke/james.html
To me, it is very clear that my complaint is about First Health’s handling of claims from April 24, 1999 forward.
The First Health response is an irrelevant rehash of previous events, and in no way addresses the nature of my complaint.
So, 1 of 2 things happened:
1. You didn't communicate the nature of my complaint to First Health, in which case First Health is innocent of any charges of not properly responding to the complaint.
2. You didn't read the First Health response to determine if it was relevant, in which case you are not innocent of the charge of not properly responding to the complaint.
Either way, my complaint has not been resolved.
My complaint does not involve benefits per se; that would exclude any oversight by your department due to ERISA pre-emption of State’s Rights.
Rather, my complaint does involve the business practices of First Health. I am a party to the contract (beneficiary/enrollee), and am paying full fees for the policy via COBRA.
My reading of Vernon’s shows that First Health fits the definition of Third Party Administrator, and is not eligible for any of the exemptions. This places them under the oversight of your department, and possible criminal charges through the State Attorney General's office.
Please reopen the complaint, address the true and complete nature of the complaint to First Health, and review any First Health response for relevancy. While the volume (thud weight) of their response was impressive, it was useless and considered non-responsive.
Thank you.
What do you consider to be a fair resolution to your problem?
Thank you.
If more space is needed, please attach a separate page.
(s) Ronald James Martin
_________________________________________________
INSURED OR CLAIMANT'S SIGNATURE
(Please print a copy of the completed complaint form for your records)
