HELP!! Blue cross blue shield unfairly denied my child?

Question

I applied for health coverage for my 5 year old daughter. She has had some urinary tract infections over the last year. She has had probably 5-6 infections and prescribed antibiotics to clear them up. She went to see a urologist who COMPLETELY cleared her of any abnormalities of her kidneys or bladder. He said it was normal for girls her age to get them and probably due to hygiene. She had medicaid at this time and now we do not qualify for medicaid or chips. I applied for health insurance from Blue Cross Blue Shield of Texas and she was denied for her urinary tract infections. She is NOT SICK! nor does she have any disorder or disease. She is a perfectly healthy child. Is this unfair and wrong or is her denial normal? I want to file a complaint against them....how would i go about doing that? Please help me, my daughter cannot go without health insurance because children get sick.

Answer 1

Blue Cross is a little persnickety at times. Have your agent do a pre-screen for your daughter with other carriers before you submit an application. Some may even have underwriting guidelines readily available in their office to refer to quickly. Each company has criteria for certain medical conditions, and Blue Cross sees your daughter's past UTI's as chronic. It is possible that after a specified amount of time with no re-occurrence of a UTI, that they will reconsider. In Texas you have 63 days to apply for or obtain new coverage without your daughter having to fulfill a 12-month pre-existing waiting period. You definitely want to find something asap even if it is a temporary policy while you are looking for a permanent one. Otherwise, when you do get the permanent one, you will have each claim reviewed very closely to make sure that is it not a pre-ex condition. I would suggest Aetna, they don't place riders on policies stating that they won't cover a specific condition. They will adjust the price if they are willing to insure your daughter. There are others, but it just depends on where you live. Feel free to email me, and I'll help in anyway I can.

Answer 2

If she had 5-6 urinary tract infections within a year, I'm not surprised that BCBS would question that during the underwriting process.

Did you or the urologist send a copy of her medical records for BCBS to review?  If not, then you may want to inquire whether the underwriting department will review her medical records and reconsider their decision.  (Does not guarantee that they will take her this time, of course...just that they might review medical documentation from the urologist, if none was provided to them initially.)

However, if BCBS has already reviewed her medical records from the urologist, then there isn't much you can do.  They based their underwriting decision based on the information provided by the doctor, and apparently your daughter didn't meet their criteria.

The insurance company does have the right to turn her down for an individual policy, based on information in her medical history.  

You can check with other insurers, who might have more relaxed criteria for acceptance on an individual policy.  Keep in mind that you'll likely pay a higher premium due to her recent history of UTIs.

Also, if you get a job that comes with medical benefits, they would have to accept her.  Group health insurance policies through an employer cannot use medical history to deny an otherwise eligible dependent.  (There are different rules and regulations for employer/group policies vs. policies that you would purchase on your own.)

Answer 3

I feel your pain. They probably denied based on pre-existing conditions, or not having a condition that was there before up to 365 days before coverage. If it is a newer plan.

There are alternatives to hospitals that can help alleviate the high costs. Look for urgent care facilities in your area. They are less expensive and offer good services.

Meanwhile talk to the representative of your plan and get them show you in your plan how they are not resposnible for the coverage. They should have some form of documentation in your plan that obsolves them.

If they can't maybe get a lawyer, although precedent doesn't allow you to collect damages, just premiums.

Find someone that will cover her right now, even if you have a high deductable. Get a private insurance if youahve to, go with a high deductable, so you can afford the premium.

Unofrtunately it seems the insurance companies control the system. As far as I know the only real avenue of complaint woul dbe to your congressman/woman to help pass laws protecting against these times of things that happens all over america.

Answer 4

I'am sorry you had to go through all of that.  I know of a great discount health benefit company that is affordable and everyone is accepted.  It isn't insurance but you still can save up to 85%.  If your interested send me a message or im.  I do hope that you find something for your young one to save some money on healthcare.

Answer 5

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Answer 6

It seems, looking at a couple of the above answers, like most people don't read the question.

Pickle is right about the denial but it's probably that the insurance company sees this as an ongoing problem that they don't want anything to do with even if she is currently infection free. It may be normal for girls to get infections but 5-6 infections in one year is not the norm.

There is no one to file a complaint with; the insurance company is within it's rights. They can deny anyone at any time for anything. Have your agent talk with the other insurance companies in your area. The agent can find out if any will accept her without you having to apply first, which will save you time.

Answer 7

Her denial for coverage for her previous urinary tract infections is completely normal.  It's called a pre-existing condition.  If she was denied coverage completely, that's rather unusual for simple juvenile urinary infections.

Nonetheless, Blue Cross can deny anyone it so chooses.  If you cannot resolve this with Blue Cross, I'd recommend searching out a different health insurance provider.

Answer 8

You can complain, but you can't file a complaint.  Do the math on those half dozen trips trips to the doctor.  They were just in denying her for many trips to the doctor.  Try another company and teach her the importance of hygiene.  Also, if she takes baths switch her to showers.  Then you could write that on your application and show the insurance company that you've done something to prevent future ones.

Bottom line is 6 visits to the doctor with antibiotics costs more money than the premium so they're just in denying her.

http://www.InsurancePickle.com

More...

Here's the proof on the shower/bath advice....

http://kidney.niddk.nih.gov/kudiseases/p...

Baths are the number one cause of urinary tract infections...so don't take them.  Again, if you treat the cause and eliminate the problem you'll have no problem getting her coverage.

Don't get a discount plan.  "Up to 85%" could be ZERO discount.  Advice for getting a discount plan should be discounted 100%.

Answer 9

Yes, you can appeal the claim.  When you get - or if you've gotten the explanation of benefits page, on the back it should give you directions to file an appeal.  If not - call Blue Cross and ask them the process.  

Also, get your doctors office involved,they will help you with the information you'll need to file your appeal.