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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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  • Reply
    December 3, 2011 at 1:33 AM

    I agree with EVERYTHING you wrote. What a headache! You are so right — I hope they have some kind of public forum board where you can post all that! (Probably not though right?)

    I have amazing health insurance but I am about to transfer to another city (2 hours away – same state) and our health care provider (Kaiser) does not operate there so I have to switch to another one (ODS) and it’s way more expensive. I’m giving birth in May and I’ll end up paying 5% of all the costs for maternity care and the birth whereas with my current insurance I never had more than a $5 co pay EVER for any services (visits, ultrasounds, the entire birth, etc). I’m so bummed! The only way I can keep my awesome Provider is to travel an hour for services. Not a great option when you are pregnant and have a three year old, right?
    But I know I’m fortunate either way compared to the vast majority of Americans. I’m lucky to have such great insurance through my work. I have no idea how I would pay for the birth (and God forbid if anything went wrong, complications, etc) if I had no insurance — crazy how our health insurance system works.

    Good for you for fighting the fight!!!

  • Reply
    December 3, 2011 at 7:39 AM

    Wow! I’m speechless. I remember the whole debacle about changing the policy and incompetent consultants.
    But THIS! Seriously?
    Unfortunately as you said, very few people will bother to fight for 150 bucks, but come on, 150 here, 200 there, and you should NOT have to pay it!
    Anyways good luck with all this insurance thing! 🙂

  • Reply
    December 3, 2011 at 9:09 AM

    What a mess! Sorry you have to deal with that right now! I’m sure there are a milion other things you would rather/need to be doing!

  • Reply
    December 3, 2011 at 1:58 PM

    I don’t know why you’re surprised about all of this since you work in the insurance industry & since you had a hard time even getting the maternity coverage. I work in health care and I’m constantly battling with insurance over claims. It’s no surprise that you’re having issues. Unfortunately it sounds like the radiology is kind of a grey area in your contract(s). I definitely can understand your frustration, I’m currently battling with Wellcare to get a claim paid from April (not my insurance, a patient insurance).

    Good Luck, I hope you can get it sorted out sooner rather than later.

    • Reply
      Elena @The Art of Making a Baby
      December 3, 2011 at 2:19 PM

      Not really surprised. Just pissed that I have to show them where it says in the contract that they are supposed to cover it. That’s not how things are supposed to work. I no longer work in insurance but even when I did, most of the time everything worked the way it should (I didn’t deal with health insurance much). And adding maternity coverage wouldn’t have been this big of a mess had it not been for incompetent people. That’s what it comes down to.

      Good luck with your patient and claim, he/she is lucky you’re helping!

  • Reply
    December 3, 2011 at 6:49 PM

    I agree with everything you’ve said. I had to do something similar on a claim for lab work for my yearly exam- even though it clearly states in my benefits schedule all lab work is included. Gah. It’s such a headache, and definitely a drain on those people who don’t understand or have the energy to correct it.

  • Reply
    Jessica Bahuaud
    December 4, 2011 at 12:17 AM

    Wow that sounds so incredibly frustrating! 🙁

    The US healthcare system is such a joke. I honestly cannot believe that a country would treat its citizens so poorly. You should move to Canada! You wouldn’t pay a penny here (albeit we do not have the year-round warm weather you love). 😉

  • Reply
    December 4, 2011 at 12:24 AM

    What a bunch of junk! I also went rounds and rounds with BCBS, and didn’t win my appeal (they denied by plan renewal because I got sick and actually had to use my insurance!). So my then fiance & I decided to get married early so I could be on his health insurance (private insurance, only spouses & children allowed). I HATE insurance companies. The whole system is messed up.

    I agree with everything you said. More power to you for sticking with it! I hope you win your appeal and that this isn’t causing you too much stress.


    • Reply
      Elena @The Art of Making a Baby
      December 4, 2011 at 9:17 PM

      I always found it ridiculous that they can non-renew you if you get sick! Say what? Shouldn’t there be some protections in place? I know that is being changed thanks to the health care reform- thankfully. But smth like that should have been done long time ago.

  • Reply
    December 4, 2011 at 8:53 AM

    I’m newly pregnant and have BCBS of Florida. This worries me, so please keep us updated. I’ll also warn that when I had my son I had BCBS. After his birth we submitted all of the paperwork that you have to submit to make sure that he was properly included on the insurance plan. A month or so later we get a huge bill from the hospital showing that BCBS did not cover the childbirth at all. They claimed that we never submitted the paperwork after birth which we did. So when I should have been enjoying my newborn and recovering I was so stressed having to file an appeal and talk to the BCBS customer service serveral times each day. It was awful. Make sure when you send in all of that info after birth that you have backup proof that it was sent. I would hate for the same thing to happen to anyone else.

    Please let us know how it goes with the appeal on the u/s costs. I have a feeling this will be a battle for us as well since we have the same insurance.

    • Reply
      Elena @The Art of Making a Baby
      December 4, 2011 at 10:52 AM

      Oh oh! So you actually have to submit the paperwork yourself? Your hospital and OB don’t submit the claim for you? I’ll definitely have to call them and find out exactly what I’m supposed to do.
      I don’t see being able to deal with that after birth so I’ll put it on hubby. He’s not great when it comes to paperwork but he’ll have to do it.

      As far as u/s, it’s funny because they covered the first two “by mistake”, but my recent are falling under whatever they all of a sudden have in their system (which is diagnostic services go under health plan not maternity). I’ll definitely update everyone here once the situation resolves.

  • Reply
    December 5, 2011 at 1:17 PM

    Does it specifically state anywhere that U/S’s are included in your maternity endorsement? It is very common for pregnancy U/S’s to not becovered under maternity coverage and the same usually applies with lab services. I had U/S’s done in my doctor’s office and it was above and beyond the money I paid for maternity services through that doctor/midwife group.

    If there is no specific statement that U/S’s are covered, then you’re probably screwed. I am a little confused at your wording, maybe.

    FWIW, I agree with you about health insurance. It’s a racket. I’m all for single payer, goverment run healthcare. When I had my son, I had a bill from the hospital for me, a bill for him, a bill for the pedi who came and checked him out, a bill for labwork. It’s amazing anyone can stay on top of all the bills. No wonder people get sent to collections! I couldn’t imagine what it would be like if I had a life threatening illness like cancer, where I was in and out of hospitals and doctors’ offices!

    • Reply
      December 5, 2011 at 1:19 PM

      I also wanted to say I had all those bills with a straightforward, unmedicated childbirth. I would’ve had at least one or two more if I had an epi and I don’t want to think about how many I would have had if I had had a c-section.

    • Reply
      Elena @The Art of Making a Baby
      December 6, 2011 at 12:38 AM

      The endorsement doesn’t specify what’s covered, only what’s excluded, which is pretty standard. However in the schedule of benefits for the maternity endorsement, it clearly states that ALL services rendered for pregnancy ( don’t remember the exact wording right now) are covered and have $0 co-pay. It doesn’t say u/s are excluded are fall under the health plan schedule of benefits. And the world “ALL” is pretty straight forward. So while the company itself might mess around and come up with excuses, I don’t see how a third party independent review ( if that’s what I have to do) wouldn’t rule that “all maternity services” means ALL maternity services, including ultrasounds and lab work.

      • Reply
        December 6, 2011 at 10:38 AM

        That’s your problem. Ultrasounds are not coded as a maternity service. They are coded as a diagnostic service. Even when they have to do with a pregnancy, they are still not a maternity service. I really don’t think you’re going to win that battle. I wish you could and would, but I think you won’t. I only had one U/S with my pregnancy (20 weeks anatomy scan).

        • Reply
          Elena @The Art of Making a Baby
          December 6, 2011 at 10:55 AM

          I do see what you’re saying. And yes it might just kill it there. However, i don’t really care how they choose to code it in the system or how the OB bills it, the ultrasounds wouldn’t have been done if I wasn’t pregnant, therefore it is a maternity service. And nowhere in my contract does it state otherwise. Whenever there is an ambiguity in the contract, it is always the consumer side that the law falls on. And as far as I’m concerned, it is pretty clear in what it says. I’ll try to take it far as I need to, just because it’s ridiculous that companies get away with that.

  • Reply
    December 6, 2011 at 10:40 AM

    Also, a lot of health insurance companies see ultrasounds as elective, not necessary, especially those that aren’t the anatomy scan.

    • Reply
      Elena @The Art of Making a Baby
      December 6, 2011 at 10:57 AM

      All of my ultrasound weren’t elective. The first was viability/pregnancy confirmation ultrasound, then NT scan, (both were covered without a copay) then anatomy and the rest I know they were coding them as IUGR, which makes it a complication I think, not elective.

      • Reply
        December 6, 2011 at 11:18 AM

        I know for me (and a lot of ladies) that the dating/viability and NT scans most definitely are elective procedures that insurance won’t cover. Unfortunately, when there is ambiguity in the contract, law will most likely not fall on the consumer’s side. I’ve been there and done that many, many times. If you are willing to put in the effort, then go for it. I think it’s going to be a long drawn out process that you may or may not win.

        At the end of the day, you do have it better than most people. I have to meet a $1600 deductible before insurance will even pick up anything. After I meet that, they only pay 80% (I pay 20% co-insurance) until my out of pocket max of $4750 ($1600 deductible + 20% co-insurance) is reached.

        I would have loved to have only paid $75 for my ultrasound. I paid $350 out of pocket for one.

        I totally agree with you, though. Insurance is a joke and you would think that U/S’s for your pregnancy would be covered as a maternity expense. I’m just being real with you and saying that it’s probably a losing battle.

        • Reply
          Elena @The Art of Making a Baby
          December 6, 2011 at 11:59 AM

          Yeah I am very happy about my maternity plan. I remember when I was working on getting it all set up it was brand new. Had I started the process of adding maternity a month before I did, I would have been stuck with a $1500 deductible and 50% coinsurance. The month I started working on it was when the new plan based on health care reform was added.
          To be completely honest, I’m not fighting this for me, more out of principal. It is not worth my time to get $150 covered, but it bothers me to no end that they would go against their own contract. And what? There’s nothing to be done?
          As far as contract ambiguity being on the side of consumer, in a court of law it is the case. In real life most of the time you can’t get through to anyone who has the authority to fix the situation.

          • Briana
            October 5, 2012 at 8:02 AM

            Just curious what the end result ended up being? I have the same plan and just paid a $75 copay for my ultrasound, but had 2 done prior without a charge. I was so annoyed. I was told many times when signing up for this maternity plan that I was to pay a one time $35 copayment then 100% is covered until I am admitted to the hospital where I then pay $150 per day.

            Hope you were able to resolve it!

          • Elena @The Art of Making a Baby
            October 5, 2012 at 9:34 AM

            I filed a claim appeal but it got rejected. Next step would be to do a third party appeal but I haven’t had time to do that.

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