Health insurer's policy translates into trouble

When she learned the cost of an operation that opened her husband's clogged arteries last fall, Maria Rodriguez was glad she had signed the couple up for health coverage several weeks earlier.

But then Blue Cross of California said Raudel Rodriguez, a 53-year-old self-employed scrap-metal hauler, had failed to disclose pre-existing conditions — including chest pain — that made him uninsurable. The company canceled his coverage, returned $1,700 in premiums and left the couple instead with a $130,000 hospital bill.

The Rodriguezes insist they answered the Blue Cross salesman's questions honestly in a telephone conversation in Spanish. If anything was amiss with the husband's application, they say, the fault lies with Blue Cross because the company filled out their applications in English, a language they do not understand.

"What we want is the deal they promised us — if we paid them, we were covered," Maria said in Spanish.

Blue Cross, a unit of WellPoint Inc., declined to comment.

With a lawsuit accusing Blue Cross of reneging, the Santa Ana, Calif., couple has raised an issue that experts say could plague the health-insurance industry in coming years as it increasingly reaches out to cover immigrants: Insurers could face legal problems unless they make sure they are doing business with customers in a language they understand.

A recent study found that as many as 10 percent of HMO members in California speak no English or have limited proficiency. Under current law, however, non-English speakers have fewer safeguards when buying health coverage than they do when buying a car or renting an apartment.

Auto dealers and other retailers that sell products with financing long have been required to put contracts in Spanish if that is the language used to make the deal, said Alejandra Cedillo, a Los Angeles County Neighborhood Legal Services lawyer. That protection recently was expanded to consumers who speak Asian languages.

"There's nothing that would apply to health insurance," she said.

That's about to change. The state Department of Managed Health Care expects to finalize rules this year that would require health plans to put key documents in the consumer's primary language and to pay for interpreters to accompany patients to doctors' offices and hospitals.

A Spanish-language TV commercial led Maria Rodriguez to call Blue Cross last summer. She said she spoke to an agent who described the plan and asked questions about the couple's medical history — all in Spanish.

The couple said Raudel had complained of chest pain early last year. But his physician had diagnosed heartburn, and they had no reason to believe it was anything more significant.

Applications for coverage — one for each of them — arrived in the mail already filled out in English, making it impossible for them to verify the accuracy of the responses. The couple said they signed nonetheless. They began paying premiums of more than $500 every other month on Raudel's policy, which took effect Aug. 1. (The couple pays almost $500 every other month on a separate policy for Maria, still in effect.)

A couple of weeks later, Raudel felt chest pain again and went to the doctor. The physician ordered tests but found nothing wrong, the Rodriguezes said.

Finally, after the pains continued, a cardiologist ordered a test that showed for the first time, the couple said, that he had coronary problems. The cardiologist warned that if Raudel did not have surgery, he could have a heart attack.

Raudel had the operation in mid-September, spent three days in the hospital and went home. A few days before Christmas, Blue Cross canceled their coverage retroactively, citing information it had discovered in Raudel's medical records.

The couple had no idea what the notification letter was about because it was in English. It was not until Raudel went in for a follow-up visit with his physician that they learned that he no longer was covered.

"We cried every day for more than a month," Maria said.

Then they found a lawyer. Jess Araujo, who practices in Santa Ana, contends that the case shows that Blue Cross takes advantage of customers who cannot speak English.

"They want to speak Spanish to hook you in, but then they want to make sure they put the contract in English," Araujo said. "Why do that? There's no shortage of interpreters."

Language is not the only problem in this case, said Robert Gianelli, a Los Angeles lawyer who specializes in insurance cases and is also representing the couple. He contends that Blue Cross is using the benefit of hindsight to discern a pattern in Raudel's medical record that his physician at the time did not.

Moreover, he said, the company examined the Rodriguez case with a microscope only to avoid paying for expensive care — an illegal practice known as "post-claims underwriting."

Industry and legal experts say there is a fine line between improper post-claims underwriting and responsible investigation of potential fraud.

"A prudent thing for an insurance company to do if it has a claim six weeks after a policy goes into effect is to get the medical records from the previous doctor to see if they got bagged," said Bob Laszewski, an insurance-industry consultant. "You'd be foolish not to ask for the medical records."

If the Rodriguezes lose, they said, to pay the hospital bill they would have to sell the home in which they raised three children, and Raudel might never receive the follow-up care his doctors had ordered.

As it is, he buys his medications in Mexico, where they are about half the price he would pay in California. But he has not seen a doctor since the couple discovered that Blue Cross dropped him.

"We can't afford it," Maria said.