I go to my doctor for medical advice, and I go to my health insurance company for insurance. So why is my insurance company making health care decisions for me?
Elizabeth Langford: When my husband and I set out to start a family, I never dreamed my little bundle of joy would come with a $40,000 price tag and a public battle with an insurance company over the definition of "complication of pregnancy."
It's no joke that labor and delivery rooms are high-drama, high-intensity places. The miracle of life is a messy and complicated business. If you've ever been present during the "pushing" phase of labor, you know exactly what I'm talking about. Doctors, nurses, daddies, and mommies all go into the L&D room with one goal ... to come out with a happy, healthy baby. Of course, it's not always that simple.
When my daughter Lily made her debut into the world last August, things didn't go quite as planned. My doctor became concerned after an hour and a half of pushing because Lily was starting to exhibit non-reassuring fetal heart tones, failing to descend, and seemed to be having trouble with her head fitting through the birth canal. My doctor told me that even if she could deliver the baby's head, there was a possibility that the shoulders might not fit, causing Lily to be born with a "bum arm." Visions of my little girl doing physical therapy as a toddler, not being able to lift a cheerleading pom pom, and struggling to participate in normal everyday life flooded my mind. The moment the words "bum arm" hit my ears, I wanted to know how to avoid it. The doctor's recommendation was to head for the OR for a C-section. So off we went.
Imagine my surprise about a month after Lily was born (without any health problems) when bills started pouring in from the hospital, along with notices from Blue Cross Blue Shield of Arizona that said my C-section would not be covered because it was not a benefit of my plan. My initial reaction was that there must be some mistake. My husband and I are both self-employed, and our PPO plan with BCBSAZ doesn't include maternity, but when we bought it, our broker told us it did cover medically necessary C-sections. So we paid out-of-pocket about $8,000 for my prenatal care, a vaginal delivery, and a 48-hour hospital stay. We never seriously considered that my pregnancy might end on an operating table.
I soon learned that when BCBSAZ made changes to my policy in October of '08, they had revised their definition of "complications of pregnancy" to no longer include a cesarean section "during labor." Meaning, if my doctor decided during my labor that my baby was in fetal distress and needed to be delivered via C-section, unless the need fell within extremely limited parameters, Blue Cross Blue Shield was off the hook.
I can only imagine that the change in the definition was driven by the bottom line. I understand that Blue Cross Blue Shield is in business to make money -- so am I. What I can't understand is the feeling that my insurance company is making health care decisions for me. I'm not a doctor, but neither is Blue Cross Blue Shield. They're a health insurance company. It makes sense to me that I go to my doctor for medical advice, and I go to my health insurance company for insurance. So why is my insurance company making a decision about what is and is not a "complication of pregnancy"? Seems to me that my doctor would be better qualified to make that determination.
Lily is now almost six months old, and during those six months, I've spent countless hours caught in the most complicated, time-consuming, and frustrating fight of my life. I've exhausted every level of appeal. I've taken my story public, created the Lily's Mom website, and written to Nancy Pelosi, Michelle Obama, U.S. senators, Oprah Winfrey (why not?!), and countless others. My next step is to file a motion for a hearing with the Office of Administration.
At my hearing, I'll be representing myself. I can't justify hiring a lawyer, and quite frankly, I can't afford it. Regardless of the outcome, I will be responsible for my legal fees. It says so in my health insurance policy. It also says that I can't sue BCBSAZ in open court in front of a jury of my peers. Your health insurance policy probably says the same thing. It's not surprising that insurance policies protect insurance companies, not patients. What insurance company would want to sit in front of a jury of moms, dads, aunts, uncles, brothers, and sisters and argue that protecting the health of a little baby didn't fall within their definition of "complication of pregnancy"?
My husband and I have appealed approximately $30,000 in medical bills related to Lily's birth, and we're not done telling our story. We figure at this point we've got nothing to lose. In the end, we've really already won. We've got Lily. She's happy, healthy, and is "practically perfect in every way." I wish I could say the same for the state of health insurance in our country.
For more information about my fight against Blue Cross Blue Shield of Arizona and to share your story, visit lilysmom.com.
|Elizabeth Langford is a freelance momtrepreneur. She writes about her experience as a first-time mom on her blog ChitChatMom, and works from home as a freelance project manager and blogger.|