In late July, both New York State Insurance Department (NYSID) and private insurer GHI informed Bronx resident Shawn Guffey that his regular visits to his psychiatrist to treat his chronic depression were no longer covered under his policy. Guffey, knew that their denial was against state law and reached out to Deputy Minority Leader and State Senator Jeffrey Klein for assistance.
“I knew under New York State’s Timothy’s Law that I was entitled to have my treatment covered, regardless of what NYSID and GHI erroneously believed” said Guffey. “I just needed help from an advocate who would ensure the law was enforced.”
Senator Klein confirmed Guffey’s suspicions and contacted GHI in early August to inform them that Guffey’s visits were covered under Timothy’s Law. The law, passed in 2007, entitles insurance policy holders to receive mental health coverage comparable to that for physical ailments. It is named after Timothy O’Clair, a 12-year boy who committed suicide after his parents’ insurance company denied Timothy mental health services he desperately needed.
“Citizens like Shawn Guffey who are aware of their rights are critical to ensuring laws are properly implemented,” said Senator Klein. “I’m glad Shawn brought this matter to our attention, and we were able to ensure continued services critical to his health while acquiring reimbursement of $262 for the money he paid out-of-pocket that GHI should have paid to his therapist.”
The root problem of the wrongly denied claims was a combination of computer error at GHI and lax oversight by the New York State Insurance Department. GHI incorrectly categorized Guffey’s employer group, the Mount Saint Michael Academy Lay Faculty Association, as having fewer than 50 members. Under Timothy’s Law, only insurance groups with 50 members or more are entitled to mental health parity to avoid burdening small businesses and organizations with excessive health care costs.
Guffey received verbal and written rejections to his claims from GHI. GHI denied the claim saying that the claim exceeding the number of allowable visits and that Guffey did not obtain pre-authorization.
“I was exasperated with the situation,” said Guffey. “So I appealed to NYSID to review the situation but all they did was accept GHI’s determination as final without any due diligence of their own.” Senator Klein’s office notified GHI that an error had been made and pointed out that Guffey’s employer group had more than 50 members, entitling him mental health parity under Timothy’s Law.
As a follow-up, the senator’s office addressed the underlying process that produced the errors and asked NYSID to review the categorization of all employer groups by GHI in its database, and all members within the Mount Saint Michael Academy Lay Faculty Association group to ensure none of them were, like Guffey, incorrectly denied claims or forced to pay out-of-pocket for medical services GHI should have paid for. Two additional claims within Guffey’s group were identified as requiring reprocessing.
Klein’s office also secured a change to the way in which NYSID reviews denials of claims relating to Timothy’s Law. In a recent letter to the senator, assistant deputy superintendent and chief of NYSID’s Consumer Services Bureau Mitch Gennaoui wrote “We instituted a procedure to request information on the group size to confirm the applicability of Timothy’s Law. This added procedure will enable us to determine eligibility rather than rely on the insurer’s claim process.” NYSID has already begun to train its examiners in this new procedure.
“We will continue to follow-up with NYSID to confirm that GHI has fully addressed any denied services or costs unfairly shifted to policy holders as a result of its mistakes,” said Klein. “I’m glad NYSID is taking measures to improve their training and review of claims so that New Yorkers acquire the medical services they are entitled to under the law.”