Illinois consumers sue health insurer Centene, saying they couldn't find in-network doctors

Consumers in Illinois and other states are suing health insurance giant Centene and its Chicago-based subsidiary Celtic Insurance Co., alleging that insurers defrauded them by overcharging them for plans that didn’t deliver promised benefits.

Six consumers, including two in Illinois, are seeking class action status for the lawsuit, which was filed Friday in the US District Court for the Northern District of Illinois.

They allege that the companies, which sell plans called Ambetter on the Affordable Care Act exchange, give customers incorrect lists of provider networks. A provider network is a group of doctors and other health care workers who have a contract with an insurance company to provide care to its members.

Consumers said that in some cases, they called doctors listed in network directories only to find that almost none of them took Ambetter plans. As a result, consumers faced treatment delays, were unable to receive treatment, or had to pay out of pocket for other doctors because they couldn’t find any in Ambetter’s networks, the lawsuit alleges.

“Plan members have difficulty finding an in-network provider and sometimes can’t find any provider that accepts Ambetter insurance,” according to the complaint.

The lawsuit also alleges that Ambetter plans “routinely refuse to pay for medical services and drugs that the plan purports to cover.” That can leave patients paying medical bills without insurance, the suit alleges. In some cases, bills are sent to collections, leaving consumers “stranded between disputing the bill for years and paying for health care that the Ambetter plan was supposed to cover,” according to the lawsuit.

The lawsuit accuses the insurance companies of violating the Corrupt and Fraudster Influenced Organizations Act, unjust enrichment, and violating the Illinois Consumer Fraud and Deceptive Trade Practices Act, among other things.

Centene defended itself in a statement Monday, saying it and its subsidiaries have worked, since the Affordable Care Act became law, “to help members and their families gain access to affordable health plans.” comprehensive, affordable and high quality on the market”.

“This lawsuit is simply one more attack on the Health Insurance Marketplace and the ACA itself,” Centene said in the statement. “Centene will vigorously fight this lawsuit and continue to uphold the ACA’s important purpose of improving the health of our communities, one person at a time.”

More than 2 million people have Ambetter plans, according to the lawsuit, and the plans are sold on Affordable Care Act exchanges in 26 states. In Illinois, about 54,000 people have Ambetter plans, according to recent rate reports from the company.

The lawsuit alleges that insurance companies often targeted low-income consumers, advertising Ambetter plans to people who no longer qualified for Medicaid, which is a state and federally funded health insurance program for low income people.

One of the Illinois consumers who filed the lawsuit, Alden Henriksen, alleges that after signing up for an Ambetter plan in 2019, he called dermatologists on Ambetter’s list of network providers and found that almost none of them accepted Ambetter. . He then called the general practitioner in his area that Ambetter assigned him, and that doctor didn’t accept Ambetter either, he alleges.

The other plaintiff from Illinois, Melody DeSchepper, purchased an Ambetter plan in January 2021 after losing her job and needing insurance, according to the complaint. She alleges that she called 29 providers who were on Ambetter’s in-network provider list or who were recommended by the Ambetter helpline, and none of them took Ambetter.

The plaintiffs are seeking damages for money they were allegedly overcharged for Ambetter’s schemes, as well as a permanent injunction that would “end the defendants’ fraudulent and illegal conduct,” according to the lawsuit.

Celtic is one of several insurance companies that have proposed rising rates in illinois for individual plans, including those sold on the ACA exchange, by 2023. Celtic has proposed raising its rates by an average of 13.7% in Illinois for next year.

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