Ideas? Friend's insurance is refusing to pay for labor/delivery,

[woodsprite]

newborn infant care, and prescription formula. This is Blue Cross/Blue Shield of NY (EPO). They apparently paid $1K out of 5K for her son (2 yrs ago), $100 for newborn well care and nothing for his prescription formula. Has anyone else heard of this? She said she even got the Attorney General's office after them regarding the prescription formula (apparently NY state says they have to pay it), and they still refuse to pay. Any idea where she should try next. Her son is 2yo and she is pregnant again, with twins! No fertility drugs - just ended up with natural twins. She said they suggested if she planned on getting pregnant again, that she look into "maternity insurance".

I have DE BC/BS and it's not like that - or at least not yet..... :( and thankfully wasn't that way when I had my kids. Anyway, thought maybe you guys would have an idea of what course she could try next.

[Christa]

1. What about the ACLU?

She can try them ...

[droidamus2]

2. That's why

That is why the insurance companies should be cut out of the health care industry all together. They know that most people can't really fight them if they say, 'well you know we've decided we don't really want to pay off on that insurance you bought. If that's a problem talk to our lawyers'. We may not be able to pass single payer but that is what we need.

[Ian David]

4. But the government will come between you and your doctor!

As opposed to the millionaire insurance company CEOs who don't answer to anyone.

[Ian David]

3. If they're ignoring the State AG, try your State Rep and/or go to the media. n/t

[phantom power]

5. I would have expected better of BCBS.

And, by the way, $1 out of $5 is pretty damned shoddy. What the hell?

[Ewellian]

6. what reason do they give for not paying?

What do her plan documents say is covered?
Is the plan fully insured or is it an employer self-funded health benefits plan?

[woodsprite]

12. They told the state "they haven't officially been denied...

It's still under consideration." That's going on over 2 yrs though.

[Interloper]

7. State Board

Take them to the State Insurance Regulation Board (or whatever it's called in your state)
When Presbyterian refused to pay for my fathers treatment for pancreatic cancer, he took them to the regulation board and won.
He has since survived pancreatic cancer for six years.

[woodsprite]

13. Wow! Best wishes to your Dad. That's fantastic!

She was lamenting that Spitzer wasn't still there. Said he'd get it taken care of for her.

[ayeshahaqqiqa]

8. that company is the worst, imho

They won't cover a very popular and common food antibody test even if the person is diagnosed with a disease caused by extreme food allergy. They don't even have their address on their cards for providers to mail claims to---I could go on and on and on. This action doesn't surprise me in the least.

[woodsprite]

14. I've noticed the missing address. It also took them a LONG time

to not use my hubby's SSN for our health plan number on our card. Other than that, we've had excellent service from our DE band of BC/BS. PA BC/BS was less so, and rather difficult when dealing with my parents medical needs toward the end of their lives.

[Coyote_Bandit]

9. In some states

maternaty coverage is optional. If your friend opted not to pay for that coverage then she may not be covered.

Not defending that - just sayin'.....

[woodsprite]

15. She thought that might be the case that the employer opted not to cover,

but she read through the policy info from work and it's supposed to be covered.

[mopinko]

17. has she talked to her employer?

do they have an hr dept/person? sounds like there is some confusion about what was bought by the employer.

[pacalo]

10. Maternity insurance?! That's insane!

I clicked onto this thread hoping to get some tips in dealing with insurance companies.

My husband, who has chronic back pain after two surgeries & everything we could think of to correct his problem, & I made the decision to contact a lawyer ifever & whenever his insurance company starts jerking him around. He had gotten two letters that required him to jump through beaurocratic hoops, then when we called the insurance company, & this in itself required jumping through a lot of hoops before getting the right person, they told us that it was only a form letter & that no action was required.

If I were your friend, I'd see a lawyer, pronto.

[supernova]

11. She should hook up w/ the local TV consumer reporter

Whoever covers Consumer Reports and possibly health care at the local TV station, make that the biggest station in their market.

They love stories like this.

[woodsprite]

16. Thanks for the info. I've passed it all along. She hasn't decided

which way to go next. Maybe she'll choose a dual-pronged attack and contact both the media and her state Rep or Senator.

[Mamacrat]

18. Medicaid

Along with the other suggestions she can apply for Medicaid. I'm not sure if they still have a "three months prior" Medicaid or something similar, but they did when I was a caseworker years ago. That means that even people who would not be eligible for "ongoing" Medicaid might be eligible for what's called "three months prior." They would look at their actual income (with appropriate deductions) for that month (each of three months applied for) and the bills incurred those months. So, she might be able to get it covered in part that way. Also, if they still have Right From the Start (or something similar) Medicaid, women who are pregnant and children under a certain age have their eligibility determined with a higher income limit than regular Medicaid, and the unborn child is considered a person when determining family size for the income limit. If at any time they had income low enough to qualify she would remain eligible throughout the pregnancy even if their income is higher at any time. So, if she had "low" income for the past three months or any current month then she "could" become eligible. Also, there is what is called Medically Needy, which is a program for those with income too high for "regular" Medicaid; it involves a "spend down" of income before bills are paid. It's probably worth applying even if initially denied just to find out what she might be eligible for. Here's a link: http://www.cms.hhs.gov/medicaideligibility/02_areyoueligible_.asp

[Shagbark Hickory]

19. How can you expect them to make money paying for all those deliveries?

Come on, they gotta live, you know.