Hi again, Part 3 of the Blue Cross soap opera.
I am now involved in a lawsuit with yet another Blue Cross. This one has denied payments for prescription drugs, doctor services, diagnostic tests, and for “durable medical equipment” DME, in this case a scooter to allow me to get around in spite of my severe Chronic Fatigue Syndrome (CFS).
When I first became disabled with CFS, I continued my insurance coverage with Guardian, under COBRA. They paid for all drugs prescribed, including one that was not approved by the FDA for marketing and had to be formulated by the pharmacist. (Components used to make it were FDA-approved as required by federal law.)
When the COBRA period ran out, I wound up joining another Blue Cross plan, a PPO. Not my first choice, but I was assured at the time that BC was a great plan in this area. (NOT!)
BC starting refusing to pay for prescription drugs right away. For one, they used a series of excuses, all lies, including that it was not a prescription drug, that it was a food additive, a food supplement, a vitamin, not a vitamin (!), and not in their formulary. For the one that had to be pharmacy formulated, they simply claimed that it was available OTC, which it was not.
As usual, when first contacted about this, they said “oh, you can’t just look at the benefits booklet. You need to look at the contract.” Unfortunately for them, we HAD the contract. After 4 times through their appeal land grievance system, nothing had changed. They still had not stated any reason for their denial of these drugs. Finally, after suit was filed, they declared that they had a “long-standing” medical policy about that drug and its coverage. They eventually showed it to us, under a strict confidentiality order. It was dated 1999 - 4 years AFTER their first denials of this drug. Longstanding indeed.
They also refused to pay for various diagnostic tests ordered by my various doctors. In explaining this when I appealed, they stated that “diagnostic services are not covered under your Plan.” There are 6 pages in the contract about coverage for diagnostic tests.
They also refused to pay for trigger point injections, stating initially that “Your plan does not provide for this SURGICAL service.” My doctor’s office called about this, and was instructed to resubmit it using a different code number. Vast improvement (NOT!): now it was “Your plan does not provide for this ANAESTHESIA service.” On appeal, they stated flatly that “therapeutic injections are not covered under your Plan.” The contract states, in black and white, that therapeutic injections are covered; no exceptions, exclusions, or need for pre-approval. BC repeated this lie a total of 3 times in writing, including once by an outside attorney after I filed a bad faith lawsuit.
When I started getting worse, and less able to walk, my doctor recommended an electric scooter for mobility. BC sent me to a “Independent Medical Examination” (IME). Their IME dr. did the tests prescribed by BC, and declared that “there is no reason why [I] should not receive” a scooter. The scooter company put the paperwork through, only to have it denied on the grounds that “the tests were all normal.” Looking at the tests in hindsight and with the benefit of seeing another of their secret medical policies, I can see what they did: they prescribed tests that if positive would bar me from getting a scooter, and if all were negative they could (and did) say “the tests are all negative” so he doesn’t need one. Heads I win, tails you lose.
When they tried to defend their actions in appeal, and later in the lawsuit, they quoted from this secret medical guideline. At least, they put quote marks around the stuff they were saying - but they left out a couple of important details that would have shifted me into the eligible category. They also, in another area, flat contradicted their own secret medical policy.
As for the lawsuit, they have defended vigorously. Four times (6 if you count reconsideration and certification for appeal requests) they have tried to have it thrown out because they claim they are exempt from state law. (The mere fact that their interpretation of the particular law they are claiming exemption under leads to logical contradictions is irrelevant; this isn’t logic after all, its a legal action.) They also started out saying “this is just a simple contract action…”, then later claimed that there is no contract action. They have also claimed that the magical incantation “as determined by the Plan” allows them absolute freedom in determining coverage. (The mere fact that many courts including federal Circuit courts, the US Supreme Court and many state Superior and Supreme courts have already ruled that this is not the case, somehow never quite makes it to their legal briefs, in spite of the legal ethics canon require “absolute candor (full disclosure) to the tribunal.”)
They have already succeeded in delaying trial twice. They have violated court orders - nothing new for BC, as I have seen a case where they agreed to settle if the suit was dropped, then refused to pay the settlement! They have also sought court orders to go through my attorney’s personal medical records, starting 4 years before I ever met him. (They later claimed that was a “mistake” - but somehow it never got corrected in court.)
Their most recent legal maneuver is to try to exclude all of our evidence. They are trying to get our expert witnesses excluded; get the court to order that we cannot reveal the secret medical policy to the jury (the original court confidentiality order explicitly says that it can be), seeks to exclude public documents available from the CDC and NIH, and even tries to throw out some of the letters between me and BC. They are also claiming that “cost containment” is not a policy they use - even though their own annual reports state that cost containment is the number one priority.
BTW, this BC had, in 1998, a record $220 million profit (oops, they are NON-profit, so they can’t have a profit - call it a “surplus” instead.) Immediately following that, they 1) requested a 30% rate increase, and 2) demanded 15%reimbursement reductions from all providers. Not surprisingly in this state, they got a rate increase - 10% - and some reductions, about 5%. Also not surprisingly, in 1999 they had another record profit (excuse me, _surplus_) of $250 million. They now have in excess of half a billion dollars sitting in various investments, not earmarked for any expenses. Gee, I wonder why medical costs are going up?