Written by Elena @The Art of Making a Baby on. Posted in My Pregnancy

I have a few rambling posts scheduled for the next few days. Just things that have been on my mind that I had no time to put here.


I am continuously amazed at how horrible health insurance companies are. I am saying this taking into account how much better Blue Cross and Blue Shield (BCBS) has been compared to other companies out there. But still, even with a relatively nice health insurance company, AND awesome health care changes that Obama put into effect, I still have to spend hours upon hours fighting with the claims department or whatnot.

If you read my blog from the beginning, you might remember the 6 months debacle to just add maternity endorsement on my current policy (read here, here and here). And yes, the excuses were “the new plans just went into effect, so support staff was not experienced with the changes” or “yes, it was the sales person mistake, and not really BCBS fault, if you consider not hiring smarter and more competent people to sell your products NOT your fault”, so I get it…whatever..I’m over it. I have the policy, even if it cost me months of headaches and phone calls.

Everything has been going pretty well with all my claims and everything until recently BCBS started putting a $75 co-pay on my ultrasounds. Now, my schedule of benefits specifically states that under maternity endorsement I pay $35 for the first visit and $0 for any other maternity from then on. After about 3 calls, I finally get a person, who knows what they are doing and they explain to me that in THEIR system it shows that the maternity schedule of benefits doesn’t include diagnostic services, and those would fall under my normal health plan benefits and therefore incur a $75 co-pay. I promptly pull out a 300 page BCBS contract that was mailed to me and re-read the whole maternity endorsement from front to back. Nowhere did it say that any of this would apply. They send the claim to Level II claims. I call back 3 weeks later- same deal: “our system shows that diagnostic services….bla bla bla”.

I once again read them the wording of MY contract and it specifically states that the endorsement has its OWN schedule of benefits and my health plan’s schedule of benefits does not apply. Now having worked in insurance, I know that most insurance companies ( especially health insurance companies) make it a point to put somewhere in the policy that that no written and oral staement from BCBS representative or any other information provided overrides this particular written document. I go through all 300 pages to find this little tiny paragraph that in fact says that My contract is the entire and exclusive agreement between me and BCBS, bla bla bla ( eat it, suckers!).

Of course, they can’t do shit to help me and I have to file an appeal.

Now what bugs me the most is that I AM NOW supposed to take time out of my precious day to look up THEIR own contract, find the right wording out of 300 pages and THEN fill out a form and write a letter appealing their misinformed decision. So their incompetence, or whatever it is in this case is costing me valuable time, and therefore money. And what about people who can’t or don’t know to search out their contract? Who just take their word for it? I don’t see a lot of people having the time, the patience or the knowledge to deal with something like that. Which means they’re screwed out of their own money.

Now of course 150 bucks for 2 ultrasounds is no big deal in a greater scheme of things, but it’s the principal. It is NOT my job to sit there and prove to you, people, what your policy ALREADY states in a very clear and concise manner.

So needless to say I am a little miffed at the whole situation. I don’t mind filing an appeal, writing a letter of explanation and quoting their own damn contract- I’m used to that type of paperwork in the line of business that we are in. I’m just kind of mad for all the people who for different reasons won’t be able to do that and end up getting {slightly or more than slightly} screwed by Blue Cross or whatever other nasty insurance company they are currently with.

And in the meantime, the head of Aetna is building another ridiculous oceanfront mansion here on an island accessible only by boat and helicopter, for his kid who will spend 1 week of the year residing there. Thank you, common folk, for giving up on $150 of your money, because it’s just too hard to fight it. No wonder most people have medical collections out the wazoo. They ruin their credit and health execs get to build another useless mansion. It’s a win-win ( sarcasm, for those who can’t tell)!

If this appeal gets denied for whatever stupid reason ( I really don’t see how they can go against their own written contract, but who knows), I am prepared to file a third party appeal ( again, thanks to Mr Obama, we now have the option to have a claim denial reviewed by a third party independent source). There’s no way an independent party would not go by the contract that was provided to the consumer that also states that it’s the ONLY contract that spells everything out.

Anyways, so I’ve got that to look forward to :) I’ve let a few things go in the past when it came to claims because I didn’t have the mental energy or time to deal with it, but in this case I found an iron clad clause in the contract itself, so I’m finishing it up out of principal, that’s for sure.


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