I am livid right now. I will try to be coherent. It's only over one $125 claim, and I know that means I have no problem at all compared to most people who are getting claims denied by their insurance. But the dishonesty and equivocating are so infuriating.
We have never been able to keep our head above water with the medical bills because of our high deductible policy. We still owe $2500 to Emory University Hospital for my husband's surgery back in April.
Still though, everything is supposed to be covered after we've reached the deductible, right? At least we have that going for us, right? Apparently not. My policy says they cover routine well-baby visits. Except now they are saying they don't.
I just got off the phone with Blue Cross Blue Shield of Georgia. I have written about my problems with insurance before. I work for a small/medium-sized company started by my father 12 years ago. We've had a lot of serious illnesses in our older workforce, and so our premiums are high, and our insurance is crappy. We have a $3500 deductible and a $7000 out-of-pocket maximum, on top of $500 a month premiums (and that's just the 40% of the premium that I have to pay; the company covers the rest).
Now that I am finally over the out-of-pocket maximum, BCBS appears to have started finding reasons for denying claims.
The American Association of Pediatrics calls for well-baby checkups at 12 months, 15 months, 18 months, and 2 years. The summary of benefits of my insurance says that routine preventive care visits for children are covered.
However, if you read in the fine print, they will only cover 2 visits a year between the age of 1 and 3. So if you have your 12 month visit the day after your child turns a year old, they won't cover the 18 month visit, even though that's an important one for routine vaccinations.
When I saw they didn't cover the $125 doctor's fee, I called to complain. They explained that yes, they do cover routine pediatrician visits, but they will only cover two. I answered that the routine calls for three, and so they are not covering the routine schedule for pediatrician visits.
I went around and around with the lady from BCBS for 20 minutes (the first woman I talked to pretty easily realized I was going to be difficult to please, so escalated me to a very nice, very Southern customer service manager named Carrie). Carrie would NEVER admit that they were refusing to cover a routine visit. She kept saying 'yes, we do cover routine visits', even though she was at the same time explaining to me that they were denying cover. She also apologized profusely that I was unhappy, but did not budge.
I told her, "You know that behavior like this is the reason some people want to regulate the insurance companies out of business. If you're not going to cover something, say it, but don't say that you cover it at the same time you are denying the claim."
She just apologized and reiterated that they do indeed cover routine well-baby visits.
I have already talked to my company's bulldog of an HR manager, and she has told our broker we are dissatisfied with the behavior of our insurance company. We'll see where that goes. Also, some red flags went up in my head, the way the lady kept perpetually insisting they cover routine preventive care for babies, even though they obviously don't--it made me wonder if they were somehow running afoul of state regulations. I live in Georgia, so I am very doubtful state regs are ever going to help consumers, but I am contacting the insurance commissioner for good measure.
I know it seems petty over a $125 claim, but considering that we have spent our year drowning in medical bills, and just found out our premiums are going up 13% next year, I have had enough.
At least it helps to validate the necessity for health care reform. Keep fighting the good fight, people.
UPDATED WITH PIC:
No doctor visits for you, messy face!
UPDATE:
However, upon doing a little digging, I have discovered that covering well-baby checks, in accordance with prevailing guidelines, is mandated in the State of Georgia (which I was suspicious was the case, given the lady's bizarre refusal to admit reality). Once I called back and cited them chapter and section of state code on the matter, they were sudden;y more willing to 'look into it,' I was given a direct line and I was promised a call-back. We'll see.
I'll keep you updated!