Hi again, Part 2 of the Blue Cross soap opera.
When I was working for a small company, they purchased individual BC policies for us. These policies all had a $2000 pre-existing condition limitation for the first year.
There were 3 of us who exceeded the $2000. One broke her foot 6 months after starting work. This was denied as a “pre-existing condition.” No amount of additional information or appeals or grievances would change that. Eventually, what did change it (15 months later) was that she had a secondary insurer through her husband’s employer, and they paid it. The secondary insurer then sent to Blue Cross a letter saying essentially “we have as many lawyers as you do, and will not only win this case but get punitive damages from it.”
The second instance was me - I tore a cartilage in my knee. The bill for surgery for this was split into 2 parts: one from the surgeon, another from the clinic where the surgery took place. The clinic (with attorney on retainer) was paid immediately. The surgeon was not because BC labeled the problem as “pre-existing condition: rheumatoid arthritis.” My doctor offered to send them the film of the surgery, showing quite clearly a large piece of cartilage floating around in the joint. BC didn’t want to see it, and would not change their denial. They continued to refuse to change the denial, until a letter from my surgeon’s attorney went out, threatening to not only sue, and for punitive damages, but to introduce a resolution into his chapter of the AMA calling on members to stop participating in Blue Cross plans. That got their attention - and they finally paid the bill - over a year after it was first submitted.
The third is the most ridiculous. A coworker’s newborn child was having breathing problems, and was taken by ambulance to the ER, and subsequently admitted to the neonatal ICU. The bills topped $30,000. BC refused to pay, on the grounds that “your contract does not provide for WELL-CHILD CARE.” As usual, appeals and grievances were futile. The hospital, being afraid of what BC could do to them in the way of delaying or denying payments, did not press BC for payment. Instead they went after my coworker. Unfortunately he didn’t have a strong player on his side, or an attorney familiar with health care and BC’s charades. He did, however, have a job offer elsewhere, and to my knowledge the bill remains unpaid to this time. (IMO serves the hospital right.)