Blue Shield screws Kos

Kos of the DailyKos blog lets fly at Blue Shield for the nightmarish, deceptive way that they've dealt with him. After lying for months on end to him and to the Anesthesiologist who helped his wife give birth about payment of a claim, they've invented a new lie and used it as the basis for not paying the claim, even though Kos pays $800 a month in premiums. When he asked the rep he was speaking to for her last name, she hung up on him.

It gets worse, the office of the anesthesiologist has letters from Blue Shield claiming that the insurance company had sent us the money directly, so to bill us for the services. Of course, we never received such money. No such checks were ever cashed (which would be easy enough to verify if they were really interested in the truth, and not shirking their duties).
So they lie to us, claiming for seven months that they'll cover the procedure. They lie to the anesthesiologist's office, claiming they've already paid us the amount owed, and to bill us directly.
And now, finally, they truth comes out -- they have a problem paying what's owed and will refuse to do so, even though they sent us a letter saying they would.

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wn

NE2D, It seems to me that the insurance should be for everything except what it states specifically on paper.

If they aren’t going to cover your pregnancy they should put it in writing. Not just as ‘preexisting conditions not supported’, but an actual list of the things they consider to have been preexisting.

Pregnancy is easily self induced (well, not self…) and so people can easily sign up with the intent of becoming pregnant a month later. To totally cover that but totally not cover someone who signed up in the first month seems ridiculous.

If they were interested in being fair, they’d pro-rate it. Instead they hope you forget to ask, thinking that pregnancy is so basic and obvious that you can’t miss it, so if you cared you’d have said something about it (you know, specific list of conditions the company wouldn’t support).

The companies are just preying on the few people left who haven’t heard that HMOs are essentially a ripoff. (Someone said theirs is different but didn’t name it, I’d like to investigate…)

Really, the answer is that people don’t want health insurance, they want a health trust. Insurance is something you get in case something very bad happens. A health trust in something you pay into intending to use it over your life. Insurance gets canceled over loopholes, the trust just may not have much in it if you hadn’t paid long. Neither will help someone who just gets cancer and needs help, but if a family was paying into a trust they would get to use it anyway they wanted to; no troubles getting the medicines or treatments they need. They could also transfer coverage, as it’s just prepaid medical.
axiomista

There’s not much coverage like that available anymore, and it’s *not* cheap.

$800 a month isn’t a cheap policy.

The kids out there that have never had to deal with serious health care treatments (many of them have been healthy enough to slide by without *any* insurance) will start learning about how these things work as they get older…even thought they seem quite willing to tell everybody how health care *should* work already.

In my experience, it’s the people who do have to deal with serious conditions who are most concerned with how the system “works” versus how it should work. There’s a huge gap when insurance doesn’t mean what it should: that if someone is ill or injured, the resulting financial burden on him is lifted while he recovers.
oregonrose

The important bit I left out was that the group health insurance I had during pregnancy was the same I’d had for several years prior. Several sharply-worded phone conversations, using PacifiCare’s own policy (which covers prenatal care, labor & delivery) as proof, eventually resolved the matter, but it left us pretty frustrated. Coupled with already being angry about the lack of coverage for hearing aids, my husband and I have no trust or confidence in health insurance companies.
cajunfj40

@MAGGIE LEBER:
“You need to make sure wherever possible that your providers are “participating” with whomever you have coverage with; this usually means that in return for being considered “preferred”, they agree to accept what the insurer *offers* for each procedure, rather than why they present as the invoice amount.”

I got a bill a few months ago from an ENT specialist who visited my wife while she was in labor for our child. Apparently, though we were in an “in-network” (what you refer to as “participating”) hospital with “in-network” nurses, “in-network” doctors, “in-network” anesthesiologists, etc, the ENT was “out of network” and thus had a different coverage level and did not count against the family’s/my wife’s “in-network deductible” or “in-network out of pocket” limits. I was totally blindsided by this one. There seems no rational way to explain how I was supposed to ensure that the doctors present and/or made available in an “in-network” hospital were all individually “in-network”. That bugs me, but all the paperwork checks out.

HSA’s seem to make sense, especially when you get a debit card to use at the pharmacy. Then a pregnancy wipes out the whole thing and you get to pay everything it doesn’t have available funds for up front, and get paid back in little increments as it gets deducted from your paycheck, and the fund cuts you a check… What’s even more annoying is that when I can’t use the HSA debit card (’cause the HSA is perpetually empty) at the pharmacy, the insurance company doesn’t know I’m paying for my meds, so they aren’t calculating it into my out of pocket cap for the year.

Got a meeting next week to hear about the “new” benefits package for next year. Wonder how that’ll go. Never once has a change meant things were cheaper…

As for MRFITZ’s comment, I’m not sure Canada would be far enough away, what with all the other U.S. nonsense going on…
later,
-cajun
Crash

I am not convinced that Kos would have been much better off had it been a government health service that maltreated him so, rather than an insurance company. His only recourse might have been to sue, whereas now he still has has the resources of the state insurance commission and attorney general to tap before resorting to that expensive proposition.

Also, I know it’s dangerous to mention the subject of capricious disemvowelment, but I have to echo Moonbat’s concern that the “pre-existing agenda” comment was squelched, while the profanity-laced “F- you, Blue Stick Blue Stone, and all of your cronies in Washington and elsewhere. Your days are numbered,” stood. It seems quite reasonable to me to mention that Kos’ clear agenda does color the credibility of his claims, whereas the latter post, though containing an excellent point about moral hazard, seems deliberately inflammatory.
Forschungsamt

One important thing to always remember when discussing Blue Cross Blue Shield Plans is to include the state/Plan you’re talking about. I assume this is about Blue Shield of California because I think California is the last state where Cross and Shield haven’t merged. BS of California has an awful reputation. Other plans have good ones. Some are for profit and some are not-for-profit. So don’t make the whole association of plans look bad. I happen to work for a very large BCBS plan which is not-for-profit and we have a good reputation and I can say I’m proud to work for it.
Klaus Ã†. Mogensen

“the Anesthesiologist who helped his wife give birth for months on end”

Be a part of the latest trend! Giving birth is the greatest thing a woman can experience. Now you can prolong the experince to last several months! Anesthesia is recommended to make the experience more enjoyable.

(Wonder what the kid’s birthday will be?)
Crash

Sketch (21): That’s about right — a health trust is basically “compulsory savings”, essentially a bank account that your money goes into before you get a chance to spend it. It’s a patriarchal approach, but a lot of people have trouble saving money (eg the kind of people with lots of consumer debt), so the alternative would be to leave a lot of spendthrifts unable to pay for medical treatment at all, or force their more prudent neighbors to pay for them.
Squidly

t’d b sr fr th csl vwr t tk ths srsly f th vctm ddn’t hv pr-xstng gnd.

Jst syng…
Robotech_Master

The thing about insurance companies is that everyone assumes they exist to pay your medical expenses. But that’s flat wrong.

They exist not to pay your medical expenses. The fewer medical expenses they pay in return for premiums received, the higher their profit margin.

Sad but true.
Talia

Yeah, expecting coverage and honest behavior from a company when you pay hundreds of dollars a month is a HORRIBLE agenda. Damned biased liebrals! Any honest blogger would be perfectly content throwing money blindly at insurance companies and letting them rake him over the coals.. obviously.. ;p
MOONBAT

I’ve worked in claims departments, and I can tell you that there are no such conspiracies to defraud individuals–even annoying leftwing twats like Kos. It’s fascinating to see him apply the exact same approach to his health insurance company that he applies to the Republican Party. Step one, fabricate a conspiracy where none exists. Step two, lacking any ability to take actual action, piss and moan.
MOONBAT

Oh, God….Look what the censor devoweled.

“It’d be easier for the casual viewer to take this seriously if the victim didn’t have a pre-existing agenda.”

How is that so goddamned threatening? These people seem hellbent to discourage any/all deviation from standard groupthink bullshit.
Flying Squid

“It’d be easier for the casual viewer to take this seriously if the victim didn’t have a pre-existing agenda.”

So you think he’s lying? I can show you hundreds of other cases in which they have screwed people over.

For example: http://www.latimes.com/business/la-fi-insure7may07,1,768035.story?track=crosspromo&coll=la-headlines-business&ctrack=1&cset=true
Thorzdad

Don’t worry…The market will fix this problem.
Oh…wait…
Robert

Maybe he should have read the Consumerist link posted here a couple of days ago!
mrfitz

I’m moving to Canada.
cheryl

Robotech_Master has it about right. I’ve been in the insurance and health care industry for almost 30 years. At the start of I worked with a group insurance brokerage and met with the CEO of a major insurance company. He asked me what was the feedback from the employers on their coverage. I started to explain the complaints regarding claim payments and he stopped me. He said, “We are not in the business of paying claims, we are in the business of collecting premiums.” That has stayed with me my entire career and has helped in dealing with many insurance companies.

Every state has an Insurance Commissioner who is suppose to help the public with insurance problems. In almost all cases all it took was a letter to the insurance company with the CC: to the State Insurance Commissioner. In only a few cases did I ever actually have to involve that office.
Teresa Nielsen Hayden / Moderator

Squidly’s just talking through the wrong orifice.
aluxeterna

“We are not in the business of paying claims, we are in the business of collecting premiums.”

Then you god damn shouldn’t be in charge of our health care system, should you! If you want to be in charge of health care delivery, you should be in the business of paying claims. If that is not a viable BUSINESS plan, then BUSINESS has no god damn right to be involved. The health of our citizens should be the first priority. Why is this such a difficult concept to get around? (Answer: Because the people in the business of collecting premiums pay a lot of money to the people who are in the business of representing citizens, to make sure that this concept remains difficult for the latter group to understand.)

Fuck you, Blue Stick Blue Stone, and all of your cronies in Washington and elsewhere. Your days are numbered.
Sketch

How does a health trust differ from a bank account? It comes out of your paycheck pre-taxes?
pgee

What’s interesting, is that if you or I used these tactics, we’d be prosecuted in a heartbeat. In this case it’s a corporation and an insurance company at that…. so… it’s just considered “business as usual”.

What’s more, (in a case like this), if you sue, Blue Cross has deeper pockets and more attorneys. What are the chances of the “little guy” winning?

I’m glad in this case they picked on someone who has a “voice”, but if a higher level executive’s sees this, it will “all go away”, and it will continue ad infinitum for the average guy…

Such is the way of the world…
Ketman

I realize that this doesn’t EXACTLY apply, but I’ve been trying to get some one to notice me for years now, and it kind of makes sense here. Sorry if I wasting anyone’s time.

I applied for Social Security disability in July of 2005, and I have not been approved YET (more than 2 years later), even though I have MRIs showing that I have multiple sclerosis. Please read the story:

The Social Security Administration
oregonrose

Here in Oregon we have Regence Blue Cross, and they’re no better here than anywhere else. Their prescription formulary stinks, and Kos’ battle with them over anesthetic during labor doesn’t surprise me a bit.

The sad thing is that we all have some sort of health insurance horror story to tell. While I’m angry at Regence Blue Cross for refusing to cover more than one or two medications for common ailments such as depression, ADHD, and allergies, my biggest complaint with not only Regence Blue Cross but all health insurance companies is that no one covers anything related to hearing aids. They’re considered “cosmetic,” not durable medical equipment, and so we get to foot the bill of $6k whenever my husband needs a new pair.

But Kos is not alone with his wife’s epidural story. When our daughter was born, PacifiCare (our health insurance at the time) refused to cover any labor & delivery costs because I’d had a pre-existing condition. And that would be? Pregnancy.
Maggie Leber

Apparently somebody believes that this insurance policy promises to pay any doctor whatever his invoiced amount is for any procedure. There’s not much coverage like that available anymore, and it’s *not* cheap. Kos doesn’t actually say a lot about what kind of coverage he actually bought.

You need to make sure wherever possible that your providers are “participating” with whomever you have coverage with; this usually means that in return for being considered “preferred”, they agree to accept what the insurer *offers* for each procedure, rather than why they present as the invoice amount.

It’s like the difference between the going wholesale price for a pallet of whatever, and what the whatever manufacturer discounts it to Wal-Mart for when they send fifty pallets of it to the Wal-Mart distribution center.

The kids out there that have never had to deal with serious health care treatments (many of them have been healthy enough to slide by without *any* insurance) will start learning about how these things work as they get older…even thought they seem quite willing to tell everybody how health care *should* work already.

Sounds to me like Kos is using his insurance for the first time for something more complex than an office visit co-pay now that he’s a daddy.
NE2d

When our daughter was born, PacifiCare (our health insurance at the time) refused to cover any labor & delivery costs because I’d had a pre-existing condition. And that would be? Pregnancy.

If I understand you correctly, you were pregnant at the time you enrolled and so the carrier refused to pay for the L & D. I won’t defend everything that insurance companies do, but this is a no-brainer. Insurance is risk-pooling and the “risk” in your case was virtually %100. You can’t schedule a surgery, go to an insurance company and pay one premium, then expect them to pay for it.
chgoliz

Here’s my favorite health insurance story:

Clean bill of health, but starting a family, so I decided to apply for catastrophic-only health insurance, just in case. Didn’t cover prenatal care, L&D, well-baby checkups, any normal adult checkups…in fact, only kicked in once $10,000 per person per year had been spent, and even then only for things like car accidents. BCBS-IL turned me down when I was 4 months’ pregnant because they said I was “infertile”.

Top that!!
RugerRedhawk

“I’m moving to Canada.”

You’re moving to Canada because this guy’s health insurance sucks? Mine seems to be fine, and I’m not going anywhere.