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Reopening of Time Period to Allow for Appeals of Partially or Fully Denied Claims

Insurance Superintendent Gregory V. Serio today announced that an agreement has been reached between the Department and United Healthcare to create an appeals process for claims that had been partially or fully denied during certain time periods. This agreement is the result of an examination that found violations of the Insurance Law by United Healthcare for failing to give proper notice of the right to appeal in its Explanation of Benefits Form.

In its recent Report of Examination, the Department found that United Healthcare had issued to certain policyholders defective Explanation of Benefits forms under a policy issued from July 1, 1994 to December 3, 2001. As a result, United Healthcare has initiated an appeals process for policyholders that received the defective forms. Advertisements detailing the appeals process are now running in newspapers through June in the Plan’s service area. This agreement is indicative of the Department’s creative new approach to health insurance regulation in an effort to make enforcement actions more meaningful for policyholders.

Certain policyholders of United Healthcare Insurance Company of New York, United Healthcare of New York, Inc., or United Healthcare of Upstate New York, Inc. who never previously pursued an appeal may be entitled to appeal partially or fully denied claims. The Companies also operated in New York under the names of MetLife Healthcare Network of New York, MetraHealthcare Plan of New York, Travelers Health Network of Upstate New York and MetraHealth Care Plan of Upstate New York. To initiate an appeal a toll-free hotline has been created at 1-866-249-9171.

This new appeal process does not apply to policyholders of coverage offered under:

  • AARP Group Hospital Plans or Medicare Supplement Plans;
  • Claims submitted under New York State Health Insurance Plan (the "Empire Plan");
  • Coverage Administered under customer self-insured contracts;
  • Coverage issued by an insurer or HMO other then the companies listed;
  • Denials based on application of appropriate co-insurance and deductible provisions and coordination of benefit payments with other carriers or government programs;
  • Claims submitted by participating providers on behalf of insureds and enrollees or claims with no patient liability; and
  • Denials for which appeals have previously been pursued.

Additionally, the Company has filed a remedial action plan for other violations discovered during the examination. The Company has also paid a fine to the Department. The full examination report is available on-line at

Department of Financial Services


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