Officials at Aetna and Cigna did not immediately have a comment and representatives for UnitedHealth and Oxford did not immediately return phone calls seeking comment. The New York Health Plan Association, which represents insurers operating in the state, said health plans generally do a "good job providing clinical review information." It said it would work with the attorney general's office to help plans raise compliance with the law. Spitzer said he would not fine the health insurers yet, but he has contacted them and if they fail to comply, he might seek punishment.

"Our mission is not just punitive. Our mission is to say we want you to live up to the statutory mandate," Spitzer said at a press conference in New York. "But we're lawyers, we're prosecutors, we'll do what we need to do." Spitzer said his office would negotiate with insurers over an agreement that would require health plans to more fully disclose their health coverage and how decisions are made. "We're saying we'll give you another chance. Not because we love you or we like you but because it's the right think to do for consumers," he said. The move is the latest among a series of consumer-protection initiatives in which Spitzer has targeted corporate greed on Wall Street and in the health care industry, making him perhaps the most high-profile prosecutor in the United States.

For the survey, the attorney general's office wrote letters from contrived customers seeking information about coverage. Each insurer received five letters inquiring about coverage for five different medical treatments: insulin pumps for diabetics, surgery for Crohn's disease, arthroscopic knee surgery, enteral formulas for people who can't swallow, and breast reduction surgery. Spitzer's office chose those five areas because they involve procedures that typically can be performed only after they are declared medically necessary under objective criteria. Several letters went unanswered by the health plans, while others elicited inadequate or incomplete responses. Only Empire HealthChoice rated a 'B' on a grading scale of A-F. Eighteen out of the 22 health plans surveyed received either a D or an F.

"The importance of this survey is to stand in the shoes of real consumers," said Joe Baker, chief of the health care bureau in the attorney general's office. "We're concerned that the plans don't really have any way of complying with the law." Insurance companies were widely criticized in the 1990s for not providing coverage for procedures that doctors deemed medically necessary and for discouraging or refusing referrals to specialist physicians. © Reuters 2004. All Rights Reserved.