Evergreen State Imposes ER Benefits Penalty

Washington state regulators have issued $65,000 in fines in connection with allegations that a health carrier violated the state’s prudent layperson rule for coverage of emergency room claims.

State officials are accusing Kaiser Foundation Health Plan of the Northwest, Portland, Ore., an affiliate of Kaiser Permanente, Oakland, Calif., of improperly denying insurance claims from 229 policyholders who sought medical care at an emergency room during 2003 and 2004.

Kaiser denied the claims after a physician reviewer made a determination that a medical necessity for emergency care did not exist in those cases, according to Washington officials.

In Washington, state law “requires emergency services to be covered if a prudent layperson, acting reasonably, believes that an emergency medical condition exists, regardless of whether a physician agrees,” officials say.