Find out which company it is and what you can do if your insurer failed to provide you with the healthcare coverage you paid for.

Many Americans rely on their healthcare coverage to help pay for routine doctor’s visits, unexpected trips to the hospital, surgery, therapy, and more. Because most medical care is unaffordable without insurance, individuals who opt to purchase it try and choose a company and policy that has their preferred doctors listed as being in-network so that they aren’t required to pay as much for a visit. To clarify, when a doctor and/or facility meets “certain credentialing requirements and agrees to accept a discounted rate for covered services under the health plan in order to be part of the network,” they are considered to be in-network.

In the event “a doctor or facility has no contract with your health plan, they’re considered out-of-network and can charge you full price. It’s usually much higher than the in-network discounted rate,” says Cigna.

Because policyholders often choose a policy according to which doctors are in-network, as well as the types of care they will be able to receive with a particular plan, it is important for insurers to always provide them with accurate information. Not only should an insurer provide a policyholder and those looking to purchase a new policy with correct information, but the law requires them to do so. Unfortunately, our Houston, Texas, attorneys have recently learned  that at least one company that offers policies in the healthcare marketplace that is being sued for deceiving its policyholders.

Centene, A Large For-Profit Health Insurer Sued for Selling Ambetter Insurance that “Provides Coverage Well Below What is Required by Law”

Centene, which is one of the largest insurers offering policies on the healthcare marketplace, has been sued after it sold its three-tiered Ambetter insurance with limited coverage to consumers. According to the lawsuit, “customers found the Ambetter provider network [to be] largely fictitious. Members have difficulty finding—and in many cases cannot find—medical providers who will accept Ambetter insurance” [Source: The Hill].

The New York Times  said that “Centene misrepresents the number, location, and existence of purported providers by listing physicians, medical groups and other providers — some of whom have specifically asked to be removed — as participants in their networks and by listing nurses and other non-physicians as primary care providers.” The news source went on to explain that when people initially signed up for their Ambetter policy, they were provided with a list of healthcare professionals who were in-network and later learned that there were no doctors who had agreed to participate in their plan.

The lawsuit questions “whether Centene offers plans that provide its customers with access to the level of care required under the law.” The lawsuit also states that “many doctors won’t accept patients covered by Centene’s [Ambetter insurance] because of the company’s refusal to pay legitimate claims.”

Interesting Fact: Centene also targets and “provides coverage to low-income individuals under the government Medicaid program” and “has proved to be one of the mainstays of the Affordable Care Act.” Although many insurers “abandoned the individual market created by the federal law,” Centene remained a provider ultimately resulting in the company becoming “one of the largest insurers offering policies.”

The New York Times shared an example of what one policyholder’s experience was like after she filed a claim under her Centene policy. The woman, who has been identified as Cynthia Harvey of Washington State, purchased Centene but found that she was unable to find an in-network doctor. The source says that “Harvey was billed for hundreds of dollars in medical costs after she discovered some of her care was out-of-network.” Harvey had gone to the emergency room in 2017 and later received a bill for $1,544. It turns out, “Centene had no emergency physicians participating in its network in the Spokane area at the time.”

The news source reported that the insurer even denied some of the claims that were filed after Harvey underwent a colonoscopy “because she was at high risk for cancer, according to the lawsuit.” Thankfully, Harvey was able to successfully appeal many of the denials she received for the care she had received.

Harvey wasn’t the only patient who experienced issues with Centene.

The news source stated that “state officials said they received more than 140 complaints from people who had trouble finding a doctor, particularly a specialist like an anesthesiologist, who accepted the insurance or from individuals who received a surprise bill after they received treatment.” Another policyholder, a periodontist from Texas, who is also one of the plaintiffs, said he was paying about $1,200 a month for Centene and chose the company “after seeing that its network included a large medical group in Austin.”

The doctor later learned that “the medical group he had picked was no longer in the network” and the “doctor’s office assigned to him by Centene was actually an obstetrician/gynecologist, a type of physician that doesn’t provide care to men.”

A spokeswoman for Centene later issued a statement via email claiming “the company had not seen the lawsuit.” She went on to say that “We believe our networks are adequate and we work in partnership with our states to ensure our networks are adequate and our members have access to high-quality health care.” Centene has been named as the defendant in various lawsuits and could be required to pay millions in dollars to those it allegedly deceived.

Did your health insurer in Texas recently deny your claim or handle it in an unfair manner?

If so, we urge you to contact Blizzard Law, PLLC to speak with one of our trusted Houston, Texas, attorneys. If your health insurer acted in bad faith, our skilled lawyers in Houston will work to get your issue resolved and get you the money you are due.


You can reach Blizzard Law, PLLC at:

5020 Montrose Blvd., Ste 410

Houston, TX 77006

Phone: 713-844-3750