Insurer Fined for Denying Breast Exams and Pap Smears
June 8, 2011 -- The MEGA Life and Health Insurance Company has been fined $40,000 for improperly denying 877 claims for breast exams and Pap smears by the Department of Consumer and Business Services.
Oregon law requires that both exams be covered. In fact, MEGA had issued a group health insurance policy to the National Association for the Self-Employed, which provided these mandated benefits to its Oregon members.
However, the MEGA policy also excluded benefits for “any routine physical examination or any other expenses that are not for the treatment of a specific injury or sickness.” MEGA denied the claims because routine physical exams were excluded. Oregon law prohibits an insurance company from refusing to pay claims without conducting a reasonable investigation.
“Oregon has decided that breast exams and Pap smears are important elements of a woman’s routine health care, and that’s why they must be included in insurance policies,” said Teresa Miller, Oregon’s insurance division administrator. “Fortunately, a consumer who was denied coverage brought this to our attention and our investigation was able to help many others.”
In addition to the fine, MEGA reimbursed its members whose claims were improperly denied.
Consumers who have questions about claim handling or other insurance issues can call the Insurance Division’s consumer advocates at 1-888-877-4894 or, in Salem, 503-947-7984.
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Thank you for posting this and I am glad to hear this company was held financially responsible for denying claims. Breast exams are indeed critical for women's health. If covered, women are more likely to have those exams which result in early detection. If a woman is diagnosed with breast cancer, the insurance company would have higher costs in chemo, radiation, surgery and possible breast augmentation for reconstruction. I am sure MEGA Life isn't the only insurance company who has tried to get out of paying these wellness exams.