**Health Insurance Struggles: A Parent’s Fight for Care**
*By Christine Mai-Duc*
When Colleen Henderson’s 3-year-old daughter expressed discomfort during bathroom visits, doctors initially dismissed it as either a urinary tract infection or constipation—common issues during the potty-training phase. After learning that her health insurance wouldn’t cover an ultrasound, Henderson opted to pay for the $6,000 procedure out of pocket. The result was shocking: a grapefruit-sized tumor in her toddler’s bladder. This incident was just the beginning of a drawn-out ordeal, leading to a five-year confrontation with her insurer, UnitedHealthcare, over the necessary treatment for her daughter’s rare condition, known as inflammatory pseudotumor.
Despite mounting medical bills exceeding $1 million, Henderson faced continuous claims denials from the insurance company, which labeled recommended treatments as unnecessary. The family was forced to declare bankruptcy. Henderson emphasized, “If I hadn’t fought tooth and nail every step of the way, my daughter would be dead.” Thankfully, her daughter has since recovered and is now a flourishing 20-year-old junior at Oregon State University. However, Henderson lamented, “You pay a lot for health insurance, hoping it prioritizes your well-being, but that’s simply not the case.”
The troubling trend of increased insurance denials contrasts starkly with the low number of Americans who appeal such decisions. Although studies show that many individuals who report their cases to government regulators succeed in overturning denials, it remains a daunting process for most. Advocates and policymakers argue that this highlights a pattern where insurance companies regularly deny essential care. In response, a new proposal in the California Legislature aims to penalize insurers for repeated wrongful denials of care.
Senate Bill 363, while applicable to only about a third of insured Californians, represents a significant attempt to curb health insurer denials both prior to and following treatment. If passed, California would join a small group of states requiring insurance companies to disclose their denial rates and the reasons behind them—data that is often kept private within the industry.
This measure would impose stringent requirements on insurers, mandating them to provide comprehensive data on denial and appeal outcomes. If insurers have over half of their denials overturned in appeals, they could face substantial fines—starting at $50,000 for the first infraction and escalating to $1 million for each subsequent violation.
Recent statistics from California indicate that approximately 72% of appeals to the Department of Managed Health Care resulted in successful reversals of initial denials. Senator Scott Wiener, who introduced the bill, asserted, “When you have health insurance, you should trust that it will cover your medical needs.” He condemned the tactics insurers use to deny necessary care as unacceptable.
While California continues to grapple with the issue of insurer transparency, other states have enacted measures targeting health care provider authorization practices. By 2024, 17 states had introduced laws related to prior authorization by private insurers. Nonetheless, California’s current lack of insight into insurance denial rates is concerning, especially amid a rising mental health crisis impacting children and young adults. Keith Humphreys, a health policy expert at Stanford, pointed out that mental health diagnoses can be more subjective, making it easier for insurers to deny coverage.
Moreover, insurers are not required to disclose how frequently they deny care, a situation that advocates argue is particularly troubling given the urgent need for mental health services for the youth. Legislative proposals like Wiener’s aim to hold these insurers accountable.
As pressure mounts for reform, families like that of Sandra Maturino hope for a future where no one else has to endure their battle against insurance denials. Maturino adopted her niece, who has struggled with serious mental health issues, but faced roadblocks when her insurer, Anthem Blue Cross, approved only 30 days of inpatient treatment despite ongoing recommendations for longer care. Maturino’s frustration peaked as her niece continued to cycle between facilities and counseling without adequate support.
Eventually, Maturino took matters into her own hands, securing her niece a spot in a residential program outside California. The health and well-being of her niece took precedence: “I wasn’t going to wait around for the insurance to kill her, or for her to hurt somebody,” she stated.
As the conversation around insurance reform continues to evolve, the hope remains that legislative changes will lead to a more equitable and supportive healthcare environment for all Californians.
*KFF Health News is a national newsroom dedicated to producing comprehensive coverage of health-related issues and serves as a core part of KFF—an independent source for health policy research, polling, and journalism.*
