Blue Cross Blue Shield Calls Miscarriage "Elective Abortion," Denies Claim


After going without any healthcare coverage for 3 years, (husband’s employer didn’t not offer it and husband and child have preexisting conditions that make self paid insurance imposable to afford) was ecstatic to find out my husband’s new employer did offer insurance! Even though it is at a very high premium and a $2000 deductible, it’s better than nothing, right? At least that’s what I thought, till I tried to use Blue Cross Blue Shield of Kansas City…

Picture: The Blue Cross Blue Shield of Kansas City management team.

I set my daughter up a doctor’s appointment for a well needed check up, and in just one weeks time was sent a statement for BCBS that they don’t cover any of procedures that was done that day! NOT ONE!? So of course I called BCBS and they were very apologetic about this “mistake” and would fix it, it will take about 10 days. A week later I receive a bill from the hospital claiming that BCBS had denied all charges. I called the hospital and told them that BCBS opened a case about this, I kid you not, the billing clerk started laughing, and stated, “Good luck with that!” She went on to say that most of their patients have problems with BCBS paying up. I call BCBS and ask them about the open case on the claim. I was told by Jerri, that someone had just closed the case. She had no idea why they closed it, but was informed that she was “on top of it” and would take care of it, which was Aug, 16, 2007, but was also informed that it can take up to 3 weeks now to fix the problem. Jerri also had a bit of an attitude, which was totally uncalled for and unprofessional.

Now, on Aug, 29 2007 my husband and I suffered a devastating miscarriage. Being near midnight we went to the ER. The hospital was very compassionate about our loss and was able to get us in quickly and expedited our treatment. The following day I called BCBS and informed them that we had made a visit to the ER, and was told it wasn’t necessary to call them just for ER visits, but only when we are admitted. Believing that BCBS would never make the mistakes at they did the previous and only time we have used our insurance I thought everything would go smoothly. Boy was I wrong!

On, Sep, 21 2007 I received a statement for BCBS that they were denying all of the claim. I called them and asked why they were denying the entire claim, and was told by Jane, “We do not cover ELECTIVE abortions. If you chose to terminate your pregnancy for non-health threatening reasons, BCBS will not cover it.” WTF!!!??? I asked her, “Are you saying that my records state that I had an ELECTIVE abortion, in an ER at 12 o’clock in the morning?” It was then, I think it clicked in Jane’s mind what she was dealing with and told me how sorry she was. I lost my cool and even started crying. I had a miscarriage not an abortion, and being treated in such a condescending way by BCBS really ticked me off. Thinking what an incredibly huge screw up, BCBS will be right on it trying to fix this, well you would be wrong. I was told to call the hospital and have them fax over my records stating I didn’t have an elective abortion. Who the heck can get an elective abortion in a busy ER at 12am, anyway?

Mind you we have had Blue Cross and Blue Shield of Kansas City for less than three months, they have denied every claim we have submitted to them. EVERYONE! Even though all claims are clearly covered under our policy, is this the going to be the norm dealing with BCBS? Any help would be very much appreciated!

-Tonya Gullino

That is a horrible, horrible story, Tonya. We are sorry for your loss. The only thing we can figure is that you need to escalate your issue past the grunts and on to someone with a portion of a brain and a silver of a heart left. We can offer several classic Consumerist tactics to achieve that effect…

UPDATE: Tonya writes in the comments:

I’m the writer of this letter. I just got off the phone with the hospital and was told that the claim was not miscoded. The billing clerk told me that the wording clearly stated that I had had a spontaneous miscarriage and not an elective abortion. I was also informed that this is common practice with BCBS of Kansas City to deny miscarriage clams as an “elective abortion.”

For those that wondered, I didn’t not have a D&C. The miscarriage was complete before I arrived at the ER.

I have been contacted by the media. I want to thank you Ben and for all the supportive comments, you all have been a Godsend.

Tonya Gullino

Comments

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  1. Buran says:

    Ugh. I’d say change your insurer ASAP and not deal with those fools. Say, at the next open-enrollment period.

  2. ceejeemcbeegee is not here says:

    There is a special circle in hell for insurance companies like this.

  3. iMike says:

    Mene, mene, tekel upharsin.

  4. mcrbpc says:

    Weird, I’ve had BCBS of KC for several years and never had a problem. After reading this though, it makes me really glad that I just canceled to join my employer’s insurance plan.

  5. CurbRunner says:

    Please tell this lady to email Michael Moore at: michael@michaelmoore.com with her story.
    Also, tell her to let BCBS know that if her coverage for this incident continues to be denied, that she has notified Michael Moore and will also be seeking coverage from her local media.
    I believe this should help move things along in her favor.

  6. samiamiamsam says:

    Uh Buran, I think the point here is that she doesn’t have any other insurance options. Many smaller companies (if they offer insurance at all) offer one carrier only. And as she stated, she’s lucky to have that.

    I recently signed on with BCBS and even more recently made an ER trip for some stiches for my son. Haven’t received a bill yet. After reading this, I really can’t wait to see what I’m in for.

  7. warf0x0r says:

    I nominate this post for most horrible thing an insurance company has done since Katrina.

  8. liquisoft says:

    Insurance companies are notoriously corrupt and backwards, and will find any reason not to support a claim. I’m very fortunate that my wife works for a great hospital, and she gets almost 100% of her visits covered while I get a very large chunk of mine covered.

    The bit about the miscarriage is especially troubling. I have a family member who has had a couple miscarriages and I can tell you it’s a horrible thing to go through.

  9. CurbRunner says:

    BY WARF0X0R AT 12:52 PM
    “I nominate this post for most horrible thing an insurance company has done since Katrina.”

    I second your nomination!

  10. This is a shocking level of incompetence and insensitivity. The entirely lineup pictured above should be shamed beyond words.

  11. erratapage says:

    Apparently, it’s quite common for an insurer to reject miscarriage claims, because the procedure is often listed as a D&C, which the procedure most often used in a voluntary termination.

    My husband always used to have his insurance claims denied. I’m not sure why. My insurance is almost always smooth sailing. I may not be happy with my benefits or their cost, but I’ve never had a claim denied. I have BCBS-MN, btw.

  12. Joy_Rebar says:

    Love the photo! A somber, all-occasions bouquet of old white guys accented by two meaningfully placed tokens: the black guy off to the side and the old white lady down in front.`

  13. homerjay says:

    @Buran: Wait a minute. From everything I’ve read, BCBS is supposed to be the best healthcare option out there but I guess its all relative. This is fucked up. I’d call the local consumer reporter anyway- whether they start to coooperate or not.

  14. samiamiamsam says:

    A miscarriage is also sometimes referred to as a “spontaneous abortion”, which might be another reason a claims adjuster would mistakenly deny the claim. Not to imply that such incompetence is in any way acceptable.

  15. chili_dog says:

    If there was ever a truism to health insurance it would be the part in the movie The Incredibles, with the little prick manager telling the employee (Mr. Incredible) to deny claims because it makes the share holders happy.

    Never seen it, go pick it up. Great movie

  16. alice_bunnie says:

    BCBS has many different regional plans so maybe KS is just horrible. However, BCBS of GA is my favorite insurer of all the ones I’ve had in the last 8 or 9 years. I’ve never had a claim or procedure denied and never had a claim problem.

    When I was pregnant with my older son I was in the hospital for a week, and I didn’t even have a copay. That pregnancy probably cost them over $30k, and I paid $10.

    The plan we have now is Humana and I think they’re trying to screw us by saying we have a deductible for every claim, however we don’t. So we always have to go back and make them reprocess. I did overlook one and ended up paying for something I wasn’t supposed to. I think they count on that.

  17. cashmerewhore says:

    It is also possible that the hospital coded her claim incorrectly, which is how they got an elective abortion denial.

  18. JustZoot says:

    Jesus, Anya, that’s an awful story. You’ll have to go over the heads of the ground-level customer service people and insist on speaking to a supervisor. If you get no satisfaction from the supervisor (and make sure you get their name and direct phone#), then do like Homerjay said and call your local TV consumer reporter.

    Insurance executives will all be giving Hitler pedicures and blowjobs when they die. That is all.

  19. bluesunburn says:

    Ugh.

    When I was a kid, my folks had BCBS of Massachusetts and as far as I can recall, they were always wonderful.

    Sad to see how things change from state to state.

  20. DorothyZbornak says:

    BCBS has fucked so many claims up here in my hometown (in NC) that the hospitals here refuse to accept that insurance. Since the two main hospitals here are both run by the same people, that means you have to go to the next town over if you want your visit covered by your BCBS insurance. Although it sounds like that might not even happen. They suck!

  21. CurbRunner says:

    BY ERRATAPAGE AT 01:05 PM wrote:
    “Apparently, it’s quite common for an insurer to reject miscarriage claims, because the procedure is often listed as a D&C, which the procedure most often used in a voluntary termination.”

    Insurers will try to interpret many procedures to deny claims. A D&C is preformed as a result of symptoms due to an abnormal pregnancy or threatened miscarriage
    (see [www.medem.com]
    cfm?article_ID=ZZZ94S7ISWC&sub_cat=2006).

    If not attended to by a health care professional, ectopic pregnancies can result in permanent damage to your reproductive organs, intra-abdominal hemorrhage, and in extreme cases the condition can be fatal.
    If a doctor made the decision to do a D&C it was most likely a necessary procedure.

  22. pparently, it’s quite common for an insurer to reject miscarriage claims, because the procedure is often listed as a D&C, which the procedure most often used in a voluntary termination.

    @erratapage: Which means that they probably know that some of them are miscarriages and are using how the procedure is listed as an excuse.

    She should tell her husband he should let HR know what kinds of problems they’ve been having. If this is typical throughout the company then they need to switch providers next year. I’m sure the company isn’t paying BCBS to leave their employees out in the cold.

  23. cashmerewhore says:

    @alice_bunnie:

    you can still go back to humana and make them repay it correctly, and then get your money back from the provider of service.

  24. Buran says:

    @homerjay: Good point. I agree with this – FILE A COMPLAINT. Please!

    From what I’ve heard, BCBS tends to be expensive. Really expensive. For what I hear people pay, I’d expect better treatment of customers.

  25. Kaneohe7 says:

    Since you have BCBS of Kansas City depending on if you live in Kansas or Missouri you might be able to file a claim with your states insurance commissioner.

    The Kansas insurance commissioners site is:

    [www.ksinsurance.org] – You can file an online claim on the website

    The Missouri insurance commissioners site is at:

    [insurance.mo.gov] – You can file an online complaint here as well.

    Not sure if it will help but good luck.

  26. lordmaxwel says:

    One of the major problems with the health care industry is that is not consumer friendly.

    On the first point where her claim was denied – had she meet the deductible of $2000? BCBS usually offers a wellness exam for kids – was this coded as such? I am betting that she still needs to meet this out of pocket deductible

    As for the miscarriage – she should not have been denied if she has met her deductible – does she know her coverage for ER visits? Some insurance it is $100 AFTER you meet your out of pocket deductible.

    If all of her claims have been denied – has she shown that there has been no lapse of coverage? She needs to send information about her last insurance dates to BCBS.

    Having a very very close family member who deals with insurance companies and claims on a daily basis – her response is always if you don’t like what the adjuster says on the phone – hang up and call a different one.

    Until she can sort this out – she will have to pay the medical bills.

    As I said – insurance is not consumer friendly.

  27. Anonymous says:

    @samiamiamsam: My mom had to battle BCBS over the spontaneous abortion tag for a miscarriage twelve years ago. I was too young to know how it got resolved – I know that it did – I just remember it being awful.

  28. mwshook says:

    [www.dmi.columbia.edu]

    ICD codes are how healthcare providers and insurers communicate diagnoses for billing purposes. The ICD-9 for Spontaneous Abortion (“miscarriage”) is 634 and Elective Abortion is 635.

    This could all be due to an extremely unfortunate typo, but even then, BCBS should be falling all over themselves to apologize in this situation. (Unless they are inhuman monsters). And sadly, it seems that if there is anything out of the ordinary, the computer programs at an insurer deny by default.

    I seriously doubt that any insurer pays for services billed under 635. I also assume that almost every insurer will pay for appropriate services for 634.

    But a bill comes into the BCBS computer with 635 and is automatically denied. And heaven help the victim of a computer fed faulty data. It’s now up to the patient to prove that she didn’t have an elective abortion.

  29. galatae says:

    Please also send a copy of your complaint to your state legislators and state medical association. Not that the government can help at all, but they can’t do anything without hard evidence that something is going on, and one more letter can’t hurt. The AMA also uses this information to help them pass patient advocacy legislation and every little bit helps. The Blues are notorious for this type of thing.

  30. MonsieurBon says:

    I used to pay $60/month for $7500/year deductible insurance from BCBS of Oregon. When I broke my leg and needed a titanium rod implanted, the bill w/out insurance would have been about $35k. Insurance reduced it to $23k, and since it qualified as an emergency, I only had to pay $2k. That seems like a pretty good deal.
    And as for the original poster, it sounds like the whole “spontaneous abortion” thing. I’m sure it’ll work out.

  31. Bobg says:

    Until two minutes ago I was against a National Health Plan. I just changed my mind.

  32. txinfo says:

    Call the press… Find every news outlet you can that will pick this us.

  33. veraikon says:

    I think I know how this happened. Doctors often have to perform a D&C (dilation and curettage) on women who’ve miscarried. For lack of a prettier phrase, they have to clean out the uterus. This is the same procedure that’s done in a “regular” abortion. So looks like BCBS’s system is set up to lump all D&C’s together (regardless of the circumstance) and try to get away with not covering any of ‘em. Go America!

  34. tundrababe says:

    Wow. I know it’s BCBS’s policy to generally deny every claim right off the bat or “accidentally” close it, but this…this is a whole new low. I hope these assholes burn in hell!

  35. bohemian says:

    An emergency room will NOT do an elective abortion. Someone at BCBS has rocks in their head.

    She should be able to get a copy of the paperwork submitted by the hospital by simply calling or going there in person to the business office. She could easily determine if the proper code was used or not. That should help with getting it fixed. If the hospital did use the right code BCBS will have some explaining to do. If the hospital did screw up they can fix it and resend it.

    If BCBS is not playing nice please do contact the insurance board in your state. They can put pressure on a naughty insurance company.

    As for the perpetual denial of claims. We ran into this with our employer provided insurance sponsored by one of the local hospitals. They denied every single claim we submitted for six months. If they didn’t deny them they would “lose them”. I found out from a couple of the local clinics that this was oh too common for this insurance company to just pretend they never got paperwork. So to get around this I had to go get copies from said clinic and hand deliver them AT the insurance company office to an employee from claims processing. I also made them sign the copy I was keeping for proof they got it.
    Ironically after that rather uncomfortable exchange our claims are getting processed. It seems they didn’t like having insureds showing up, even polite ones.

    BCBS owes this woman a huge public apology and she should go to the media with this.

  36. J. Gov says:

    BC/BS is managed state by state, so your quality of service depends on where you are. It’s been good to me so far, but I’m in Michigan.

    My GP, however, frequently miscodes and then attempts to charge me full price. I’m fairly sure it’s them and not my insurance, because there’s a consistent pattern of what gets denied, going back to when I had other insurance – not to mention that the four specialists I’m seeing (dentist, etc.) have never given me a full price bill for a covered service. It’s possible the hospital miscoded, and it’s possible that BC/BS of Kansas stupidly misinterpreted the claim.

  37. hornrimsylvia says:

    If we had single payer health care, we wouldn’t have to haggle over the phone with someone on the other end concerned about company profits and quarterly reports. Don’t forget to executive carpet bomb your congresspeople too!

  38. j-yo says:

    Try to find someone sympathetic in your local media (perhaps an investigative reporter) to report on your experience. Explain what you’ve been through in exactly the same clear way you explained it to The Consumerist. Our local newspaper has done investigative pieces regarding regular people getting screwed by their insurance companies and *surprise!* very often, the companies have followed up by stating that they will be taking care of the mistakes.

    Also contact your state insurance commission and file a complaint. The insurance commissions in some states are more on the ball than in others, and I don’t know how yours stacks up.

    I do wish you well.

  39. Raignn says:

    I’ve been with BCBS for about three years now and never had an ounce of problems. That is until last week when I got a “late” bill from my last doctor saying they had denied by doctor’s appointment due to lack of insurance. I had this appointment 15 days before I switched from my BCBS insurance to my husband’s. So I’m not looking forward to the mess of fighting I’m going to have to do either. That being said, this is inexcusable behavior. I’m very sorry for the miscarriage and the horrible treatment. I couldn’t possible hate insurance companies any more than I do right now.

  40. jaewon223 says:

    just goes to show what a sad state our medical practices are in one of the most richest country. this story is moving up on digg, hopefully it will get more attention it deserves and she finds resolution (like a different health insurer)

  41. renilyn says:

    I too have had issues with BCBS. Texas (Fort Worth Area), as opposed to KS. I had an ER visit for what I expected to be an alien in my skull (incredible head pain that I could not function with). The billing folks at the hospital CALLED the lovely BCBS and they gave their approval for me to be admitted, along with approval for several tests. Two months after I was released, I was billed for approximately $14k for that stay in the hospital-and BCBS denied all but approximately $100 of the entire visit ($100 was my ER co-pay mind you). Years later, I will still not pay the bill, the coverage was not over any bounds and it was ALL pre approved.

    I give UP!

    I am sorry Tonya, for your loss-Godspeed.

  42. VeryPlainJane says:

    I’m the writer of this letter. I just got off the phone with the hospital and was told that the claim was not miscoded. The billing clerk told me that the wording clearly stated that I had had a spontaneous miscarriage and not an elective abortion. I was also informed that this is common practice with BCBS of Kansas City to deny miscarriage clams as an “elective abortion.”

    For those that wondered, I didn’t not have a D&C. The miscarriage was complete before I arrived at the ER.

    I have been contacted by the media. I want to thank you Ben and for all the supportive comments, you all have been a Godsend.

    Tonya Gullino

  43. kabes says:

    I am glad you’ve been contacted by the media. Your issue will be resolved for sure now.

    Sure am glad I live in Canada..

  44. apropo says:

    My wife and I have had BCBS of California and had no end of trouble. They would routinely deny claims request more information, then deny again and ask for more information.

    We had a kid in July and the last claim wasn’t paid until the following June. Obviously, every region has Blue Cross administration of its own, but your story doesn’t surprise me at all.

    Another case: wisdom teeth procedure. Called insurance and there was exactly one Oral Surgeon that was “in-network” in the whole state (we’re in another state, using CA insurance, part of the nightmare). So we drive an hour each way to get the procedure done. That was 8 months ago and they have have yet to pay the claim.

    I’m happily in another job with a different insurer now.

    Good luck.

  45. ElizabethD says:

    Tonya, good luck. I hope local media coverage gets some BCBS action in your favor for a change. I trust Consumerist will follow up on your story here, too. Having a miscarriage is bad enough (BTDT) without this additional horror.

  46. Anonymous says:

    I work in a medical clinic and I deal with the terrible administrative on goings at insurance companies. I would HIGHLY suggest that anyone having a problem with their insurance, doument all exchanges with them and then right your state insurance commisioner and your state representitives. They need to be aware of these problems! Make sure you send the same letter to your insurance company!

  47. Meowcrash says:

    I have insurance through BCBS TN with a maternity rider and it states that the “Maternity rider must be in place for 10 months before benefits are provided.” (For the two months it took them to approve my application, I prayed extra-hard that I wouldn’t accidentally get pregnant.) Since she’s only had the insurance for 3 months, could they be trying to deny the insurance because those 10 months had not elapsed? I thought we would be covered if conception occurred after I was approved for the policy, but now I’m wondering if they will cover anything related to pregnancy until that 10 month mark. Tonya, I am so, so sorry that BCBS is putting you through this.

  48. BrockBrockman says:

    I would consider suing the hell out of them. “Bad Faith Insurance” doesn’t adequately describe the horror of the situation, but it is a valid legal claim, and may apply in this situation.

  49. Major-General says:

    @alice_bunnie: BCBS of Kansas City is rather Missouri and Johnson/Wyandotte counties in Kansas. The rest of Kansas is a different BCBS.

    And yeah, they have a reputation for pretty much denying everything.

  50. Anonymous says:

    Tonya, I’m very sorry about your loss. I don’t normally respond to internet posts but I thought my experience might help. I used BCBS of Texas for several years. Every chance they could they denied my claims. I was on the phone with them at least 2 hours a week for a while. What finally got me through was finding a good representative who cared. I got the rep’s name and extension and only talked with her for all my denied claims. I documented every call and kept very thorough records. I once asked the rep. if BCBS purposefully denied claims hoping to pay less. The response was of course not, but I NEVER had one claim work as it should. I would also suggest to keep very close track of your deductible. They tried to say I hadn’t met my deductible 3 times one year after I had met it 3 months before! And of course, even though I met my out of pocket, any doctor not on their “in network” list was hardly covered. It took me over 1 year to settle a claim once. In that time I must have called over 2 dozen times and was told they would “take care of it” on half of those calls. Finally my doctor and I made a call during an office visit and forced the representative to fix it while we waited. I know my advice is basic and that you deserve much more from your insurance company. I wish you and your family the best of luck dealing with these devils.

  51. formergr says:

    Wow, when I read this at work on my RSS feed I was thinking the entire time that it was a miscode of elective abortion vs. spontaneous, as others posted here, ar at least an issue with a D & C. I’m really, really surprised that they had it right all along. Tonya, thanks for posting and clarifying. I’m sorry for your loss and hope that this at least gets cleared up soon.

  52. rjhiggins says:

    This is, unfortunately, an extreme but hardly unusual example of the state of medical insurance in our country — for those who are lucky enough to have any insurance at all.

    And yet most Americans still oppose some type of national health care. I don’t get it.

  53. Jordan Lund says:

    She needs to contact a lawyer, not the media.

    This seems to be SOP for insurance companies… Deny the claim, deny the claim, deny the claim. They figure a certain percent of policy holders won’t go through all the rigamarole to get the coverage they are paying for.

    John Grisham even wrote a novel about it about 10 years ago… The Rainmaker?

  54. CurbRunner says:

    @VeryPlainJane:

    I hope everything goes well for you Tonya.
    Please write a follow-up letter to let us know how
    your claim turns out.

  55. paranoia2mb says:

    I am not downplaying any of this, but I currently work as a member service rep for BlueCross BlueShield of MA. The fact that everyone considers us to be morons just makes us not want to help you–none of us are stupid (at least in MA…). And honestly, if you want something, you have to be nice. I help people on a daily basis when they are nice and I get many many member praises for being helpful and considerate of someone who is having a bad day, a rough medical situation, or if they just didn’t understand. Something that everyone should know is that all the BlueCross and BlueShield’s are not one company. They are all individually maintained and owned, and all have their own policies and practicies. To say “BlueCross and BlueShield” and not “BlueCross and BlueShield of Kansas City” in the heading is completely misleading. While we do work together, we rarely contact or speak to one another. BCBSMA is an excessively nice company and we are trained that way. I pay things for members all the time given the situation requires it, sometimes 10+ times a day. We are trained this way so that people don’t consider us “morons” and so that we keep our members. I can’t speak on behalf of Kansas City (I’ve never actually had to call them and I’ve been with the company for over a year now), but to be blunt–this would never happen at the BCBS I work for–dead serious. When you have a policy through an employer, unless the employer has told us something out of the ordinary (such a waiting period), there are no pre-existing clauses and we will not deny things ‘just because’. I’ve never seen it and never will.

    My best advice to ALL of you is to TAKE INSURANCE SERIOUSLY. People expect it to be a godsend but you have to know what you’re paying into each week! Read your contract before signing. Make sure you understand what it says before you expect them to pay for something you have done. Some employers are trashbags and specifically design a policy NOT to cover things because they don’t want to help you pay for the policy premium. All policies are different and so some may seem like they ‘cover nothing’ but that could be your own fault.

    In this situation, I want to rip their heads off. It is making the insurance industry look horrible and all insurance companies as a whole.

    Just my two cents.

  56. hills says:

    Sorry Tonya – welcome to my world! With a rare muscular disease I have many simple things automatically denied by BCBS (VA & IN). Usually after several phone calls it is sorted out, but if they uphold their denial I file an official appeal – I have had 5-10 of those (lost count!) and won every single one. I even went to a meeting with 10+ BCBS reps at their headquarters in Indianapolis, and embarassed the pants off their “medical expert” who couldn’t explain to the group what my disease was – seriously, not even a word! One of the sweetest moments of my life – those guys suck! (That said, they do eventually pay for my very very expensive claims and I’m happy for that)….

  57. swalve says:

    @paranoia2mb: I’d also like to add to this. I live in IL and have BCBS-IL. I’ve never had any problems, they pay what they are supposed to.

    But one thing that people need to know about any insurance company is that it’s not one size fits all. They sell a variety of plans of varying quality. From my understanding, larger employers negotiate coverage and service levels. A $2000 deductible sounds like a pretty cheap plan. That’s a lot of uncovered medical care.

    Did she look at her policy to see whats covered and whats not?

  58. ElenorR says:

    @swalve:
    The OP said: Even though it is at a very high premium and a $2000 deductible, it’s better than nothing, right? .

    Admittedly, not detailed, but the impression is given that it is a small company that only offers the barest minimum of health insurance.

    The OP also says: Even though all claims are clearly covered under our policy,

    It seems to me that emergency care for a miscarriage (by law, pregnancy is NOT a pre-existing condition, so care for any aspect of a pregnancy cannot be denied) and a routine check up for a child (covering preventive medicine for children is also required by law in most states) should be covered.

    My guess is that because the insurance is so new, the claims are being denied because of a database error and someone’s incompetence, not because the OP isn’t covered, but I am only basing that on what the OP has stated, not on any actual knowledge.

    The other possibility is that that the insurer is in the business of dragging its feet, knowing that many people with this sort of insurance don’t have the resources to push back on denied claims. It is always easier to make a profit off the poor as opposed to the rich who can afford to hire advocates.

    My heart goes out to the OP, that is a horrible experience. I hope that her insurance company has a PR nightmare to suffer and restitution is paid before this is over.

  59. Arntegio says:

    From about 12 to 17 I had no insurance, and suffered a concussion when I was 15. Never saw a doctor about it, because we simply didn’t have the money. Had a soft spot on my head where I hit pavement for over a year, and memory problems arose shortly after. My mother’s company insurance wouldn’t cover me, so she paid for it herself, getting me on a Blue Shield plan here in California. I was thrilled, because the memory problems started getting worse: I’d forget something I was just told, forget why I entered a room, and had trouble remembering things I knew before, like phone numbers.

    At first, it was alright. I saw a doctor and she deemed it a concussion and referred me to the UCSD medical center, where they decided I should have an MRI. But while the doctor’s visit was covered, they immediately dropped me after the bill from the UCSD medical center was sent, claiming the concussion I’d never had diagnosed or treated was a pre-existing condition. So I had a $200 consultation to pay out of pocket, and never got my MRI because the cost was too much.

    And now I’m 21, still have memory problems, and now that it’s been “diagnosed” I can’t get insurance or have anything done about it. Hurrah for the insurance industry.

  60. jstonemo says:

    National insurance sure as hell isn’t the answer. You think the ERs are crowded right now, just wait until everyone has a “emergency” because of a hang nail or other stupidly minor injury because it is “free”.

    Insurance isn’t the answer to any of the problems in the healthcare industry in the US. Insurance in its current form IS the problem. We are not directly involved in the prices as true consumers should be. Without competition, it has become a monopoly of sorts. It is the consumer vs. “insurance companies”. We can’t go to the doctor and save money by paying cash because the self-pay customer pays a much higher rate schedule than those with insurance. For instance, my wife needed throat surgery which is normally billed at around $4000 but insurance pays them right around $1000 because of their contract with that hospital and doctor. So if you pay with cash, you might get them down to $3000, but that is still much higher than the insurance contract payment.

    In a competitive marketplace, insurance should only be needed for true emergencies or catastrophic illnesses. You don’t go out and buy auto insurance and expect them to pay to have your car’s oil changed or to have your tires rotated every 6,000 miles. It is for accidents/catastrophes. Unfortunately, we have a long way to go before a free marketplace in health care exists.

    BC/BS KC should pay for this ladies emergency no matter what. It is disgusting to be treated this way by any corporation, especially one that is supposed to pay for health emergencies.

    I live in the KC area and wouldn’t be surprised to see her story on the local news soon.

  61. swalve says:

    @jstonemo: Think of health insurance as more of a maintenance contract.

    If everyone had health insurance, they wouldn’t have to go to the ER for “hangnails” because they would have access to a regular physician.

  62. CumaeanSibyl says:

    @Jordan Lund: Yeah, I thought of The Rainmaker too. The company in that book had the bright idea of denying all claims for a year to see how much money they could make; I doubt a real company would be quite that daring, but incidents like this make me wonder if some places have policies on denying claims of specific types based on easy excuses and low risk of customer reprisal.

  63. GregC1968 says:

    I am a physician and I have some advice. Talk to your company’s HR department and ask them to agitate the insurance company on your behalf. Insurance companies often disregard physicians as we cost them money by rendering treatment. However, if the people who pay the premiums (ie employers) start getting upset and let the insurers know, the insurance companies will often become more responsive, fearing the loss of business at the next renewal

  64. dokieartiechokie says:

    This no surprise, sadly. My daughter’s birth earlier this year was initially denied by BCBS in New York/New Jersey area (2 days in the hospital, over $8K in charges). Come to find out, the claim was denied because her BIRTH WEIGHT was ENTERED IN THE WRONG BOX.

    Claim denial is the default with these people. There is a special room in hell reserved for them, I pray.

  65. alice_bunnie says:

    @cashmerewhore:

    Thanks, I’m doing that, but I shouldn’t have to. :)

  66. GregC1968 says:

    I agree. You shouldn’t have to. It should change, but won’t anytime soon. I’ve had to take the steps I described above to get my mom’s cancer treatments taken care of by her carrier.

  67. Trackback says:

    And of course, denies this woman’s claim. Just…wow.

  68. divabat says:

    Oh dear! I hope all goes well with you Tonya!

    I had a similar experience with a Malaysian insurance company. Normally I’ve had pretty good experiences, but this one just boggled me.

    I was travelling internationally (study abroad tour) and in my first night in Germany, I fell down the stairs (a LOT of stairs, in the dark!!) and had a concussion. I was rushed to the hospital to check that I haven’t broken anything. Thankfully I only had a sprained ankle, but of course hospitals aren’t free and I needed to get treatment (my foot was wrapped up for a while and they gave me anti-thrombosis injections, plus the ambulance) so we needed to pay that. My study abroad company covered the costs for me and I was to pay them back using the insurance money.

    This took longer than expected because of one thing: the insurance wouldn’t cover my ambulance fee. Why? Because I didn’t call the insurance company BEFORE an ambulance was called.

    I’m in the middle of a new country, it’s my first night there, I’m too passed out to think about calling anyone, it’s my host family (a Catholic monastery, interestingly) that called the ambulance, I JUST FELL DOWN A LONG FLIGHT OF STAIRS – and they won’t cover my ambulance fee because I was in too much pain to call Malaysia in the middle of the night?!

    Luckily they decided to pay up when we brought all that up with them. But seriously, insurance logic can be really really strange.

  69. MikeT says:

    Calling your husband’s employer is a great idea. With a corporate policy like this, the company is considered to be the customer, and keeping THEM happy is priority one. Helping your husband sort out problems with the insurance company is part of their job.

  70. chgochick says:

    I’ve been dealing with BCBS issues, but only because my employer didn’t pay the bill. I have no complaint with BCBS, but after doing some digging on getting private insurance I was dumbstruck as to the number of people who do NOT have health insurance. And even if you do have health insurance, the deductibles, premiums, and (as your situation illustrates) the crap that goes on to get a claim paid is sickening. How is it that the only ones who appear to be making any money in healthcare are the insurance companies?

  71. North of 49 says:

    A friend of mine in WA fell and put his hand through some glass or heavy hard plastic by accident – not a window. So, while his hand was bleeding, instead of just going to the ER to get it checked, he called up his insurance company first, waited at hoome for an hour for permission to go, meanwhile, he was leaving abloody trail from his woods. I just sat their agape because I couldn’t believe he wouldn’t just go.

    The more stupid thing was the insurance company said “why didn’t you go?” Uh.. because he wanted to make sure the injury was covered, maybe?

  72. NoWin says:

    @paranoia2mb: …The fact that everyone considers us to be morons just makes us not want to help you–none of us are stupid (at least in MA…). And honestly, if you want something, you have to be nice.

    You miss the point. The point is BCBS screwed her first. Why should anyone be nice subsequent to THAT?

  73. RvLeshrac says:

    @paranoia2mb:

    @NoWin:

    More importantly, all insurance companies are base scum. And *I’M* the apologist here.

    I’m against the people who say “If you don’t like it, just get another job,” but in the case of insurance services, you need to GET ANOTHER JOB. NOW. Working for an insurance company merely makes you a part of the biggest problem this country faces. As a rank-and-file employee, you don’t have much to say about corporate policy – but in an insurance company, you are indirectly responsible for the deaths of people due to denied coverage. Insurance companies don’t give a good god damn about people, they only APPEAR to “care” as long as they’re getting money and don’t have to pay it out.

    And insurance companies will try EVERYTHING THEY CAN to not meet their obligations, including lying about you, lying about your procedures, and digging up the most irrelevant bullshit from your past. ALL of them. If it hasn’t happened to you yet, you probably haven’t REALLY been sick.

    As much as I hate Michael Moore for ‘Farenheit 9/11′ and ‘Bowling for Columbine,’ he hit the nail on the head with ‘Sicko’.

    BCBS in Georgia denied my mother’s claim for various procedures and medications she needed, and we came within inches of being forced to sue them. The only reason we managed to get the money is because the state insurance commissioner got involved, and have a family friend as a lawyer who offered to work without payment.

    If my family had been one of the millions of people who DON’T know the law or have access to free legal help, we would have been SOL. Paying nearly $1,000/mo for insurance premiums due to my mother’s condition, and then having the insurance company deny care for the very same condition which they used to justify the ridiculous premiums, is just adding insult on top of insult on top of insult.

    I, however, say forget about the national health care for now – what we really need to be doing is putting the scum that unjustly deny coverage in jail – for an EXTREMELY long time.

  74. Hiketeia says:

    I´m from Argentina. A pretty screwed up country as it is… but I just don´t get it.
    I mean, we are called “a third world country” (and unfortunately, we are) but here education (since elementary school to the best university of the country) is 100% free and ANYONE can access to it.
    I would love to be informed about how the “insurance system” works and if you have any political party with new ideas about how to make it affordable (for not saying FREE) for all…
    If you think the “insurance system” is better, I would LOVE to hear why is that… I wonder all the time why in a country so full of opportunities as yours, your government seems to try to deny you health and education.
    If this is not the place to discuss these things, maybe you can recommend me a good forum or similar on the web.
    My spelling sucks, and so does my english, sorry about that =(

  75. forever_knight says:

    @Meowcrash: “Maternity rider must be in place for 10 months before benefits are provided.” (For the two months it took them to approve my application, I prayed extra-hard that I wouldn’t accidentally get pregnant.)

    so all that praying worked?? i would think an easier method would have been using contraceptives (or abstaining, if you have the willpower) if it was that important to you.

  76. gtobynj says:

    I’m just loving the comments on this one. Speak to a supervisor – good luck getting hold of one. Fax bomb them – good luck finding a number that works! Speak to your State Insurance Commission – they are more toothless than a newborn.

    How, pray tell, do I know these things? Simple, a month after my daughter was born, Aetna cancelled my health coverage and back dated the cancellation to two months prior to her birth so we were left, quite literally holding the baby. We tried everyone, every number, the State Insurance commission, etc. Nothing, everyone was terribly sympathetic, but could do nothing to move Aetna to do anything – they wouldn’t even release our medical records with them.

    Good luck, but health insurers are evil and make tobacco companies look like saints.

  77. Anonymous says:

    The company I work for changed to Aetna on July 1, 2007. It has also been a nightmare. I had surgery in August that I had to get pre-approved because the doctor I was using wasn’t in my network. My doctor is a gyn oncologist and is 150 miles a way. She is only one of four in the entire state and the closest to me. After talking to four people including a supervisor (who was extremely rude), I finally got the pre-approval so my insurance would pay as in network. After my surgery, I received a notice that I chose a doctor and hospital outside of the network so they will not pay but 60% after my $9000 out-of-pocket expenses. I have been going back and forth with them since then. They are “working on it”.
    They were also supposed to transfer any deductible I had paid and out-of-pocket expenses I had incurred this year from my previous insurance. That, of course, wasn’t done either.

  78. pattymc55 says:

    Having a son diagnoised with a rare autoimune disease in the early 90’s, I’m well versed in dealing with denial of coverages. It’s a game the Insurance Companies play, called hold on to the money as long as they can. People die or become uneccessarily crippled like my son while they play their game of denial. It is time for Universal Health Care if it is good enough for Congress it should be availabe to us their employers. To the BC Rep. are you saying that you will deny or delay coverages because someone was not nice to you? Yet another reason for Universal Health Care. Try walking in our shoes, not only are we dealing with a very ill loved one we are forced to play your game of denial. After years of doing this yes we become a little angry.

  79. lilredincali says:

    I know what you’re going thru. Dealing with insurance companies is tough. My advise is to CALL, CALL, and CALL. When I was 6 months pregnant, my X-employer switched insurance companies. I had already been on the old plan via Cobra for 2 months. The new insurance company kept billing me and telling me I owed them for those two months since, I was no longer employeed by my employer, I kept telling them I paid the Previous insurance company for those two months, since my employer had NOT YET SWITCHED! I kept telling them that they were going to make me have my baby early, and, sure enough, my daughter was 6 weeks early and had to spend 10 days in the NICU! Total bill: $48,000!! Boy did they get it in the end!! They had to cover it. But I tell you, there were days that I fought with them so hard to get the date situation corrected that I was unable to get out of bed, I’d lay there and cry till I passed out.

    Keep fighting and don’t give up!! Have someone help you, cz there will be days that you’ll think you can’t fight anymore.

  80. Anonymous says:

    Why am I not surprised? BCBS of Kansas City is the worst health insurance company I have ever had. The people who run this have definitely profits in their minds over being human. They deny claims left and right. They are expensive for what they offer (co-payment, plus deductible plus so-insurance). No decent doctor in the NYC metro area takes this insurance so I find myself going out of network and get my claims rejected or refunded so little it is pathetic. Hopefully the money they are keeping from me will help book a good ticket to hell where they will be going for the way the profit from people’s suffering. Shame on these people for putting greed over humanity. Hope this is one of the first companies that goes out of business once the national health care bill passes.

  81. careypennington says:

    Tonya, I hope you get a chance to read this. I’m an agent in another state and REFUSE to appoint and offer Blue Cross Blue Shield products. I am out in the field every day and have talked to thousands and thousands of people about health care. I know what works and what doesn’t from the stories that I hear. When I keep hearing the same name come up over and over and over and over and over and over and over and over and over and over and over and over and over and over and over and over and over again, it could only mean there is a problem with the insurance carrier and it can’t be ignored. Almost on a daily basis I hear a story and I can say, “Let me guess, you have BCBS.” They are stunned that I know. I hear stories of people being denied because the chemotherapy and/or radiation treatment for their cancer was denied because “it wasn’t reasonable and necessary” I’ve heard of people needing bone marrow and BCBS turning down the claim stating that BCBS doesn’t cover “cosmetic” procedures. WHAT? I hear it so often that I KNOW there is a problem. So many times business owners will take the insurance because the rates seem like a better deal. Caveat emptor! ……hello? There is a reason the rates are lower! I’ve heard way too many horrific stories about BCBS – anyone reading this – TAKE MY WORD!!!!! STAY AWAY FROM THEM!!!!!!

  82. 3puttblues says:

    I’ve got a problem I would like help with. I was diagnosed with prostate cancer in late July and after several hours of research decided that proton therapy would be the best option for me (I’m 49 and was very concerned about “quality of life” issues that are heavily involved after surgery).
    I did several more hourse researching the different proton therapy centers around the country and found that Loma Linda Medical University would be (in my opinion) the best place to go mainly due to the fact that their insurance charge was approximately $44,000 compared to MD Anderson (Houston), etc. being around $100,000 for their insurance charge. This would be just a little more than what the surgery, radiation would be considering the costs involving the “after-care” issues. I also think it was my responsiblity to not just think that “it’s only money” and pick the first spot to try and get treatment.
    We faxed our authorization to BCBS of Kansas City on Oct. 6th and received a phone call from one of the supervising nurses to tell us that there was an amendment passed stating that proton therapy wouldn’t be covered and that amendment was passed on OCT 6TH!!!!!!! Hello, you are telling me that they passed an amendment to DENY a treatment option to prostate cancer that is not even offered in that network the SAME DAY THEY RECEIVED OUR FAX???
    When I received the decision letter the only reason stated basically said that Proton Therapy was not medically necessary (the same ole excuse huh?). We have started our appeal but I really feel the chances of the appeal being overturned are next to nothing.
    It is amazing that the BCBS networks of Texas, Oklahoma, Illinios (just to mention a few) do cover proton therapy for prostate cancer and then to get this was unbelievable. I also forgot to mention that I did ask them for a copy of the “new” amendment and was told it was ready for public review and also couldn’t be found on their website. I thought when you receive the decision letter whatever reason they used to deny coverage had to be stated or produced on that letter.
    Like I said we have started our appeal but I am concerned that the timeline for this is concerning me (I know prostate cancer is slow, if it remains in the prostate, but I can’t get any guarantees that it isn’t anywhere else. My Gleason score is 6 which is moderately aggressive).
    Any help on this would be appreciated. I thought by trying to find economical ways to get this treatment would benefit me but dealing with this company is a joke.