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Lily's Mom vs. Blue Cross Blue Shield

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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?

lily langford

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.

elizabeth langford

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.




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11 comments so far | Post a comment now
just saying January 29, 2010, 4:34 AM

That is exactly why we need “real” health care reform and not this nonsense that Obama is trying to pass. The propose health care bill does nothing to hold the insurance company accountable or maybe it does but who could tell because nobody really knows what in it. If you really think writing to Nancy Pelosi will help you then you are sadly mistaken, that women doesn’t care a bit about us “regular people” Good luck with your fight.

mom of 2 January 29, 2010, 6:03 AM

So what does the insurance company want you to do? Call them up and go through an automated phone system WHILE YOU ARE IN LABOR so that your doctor can get a pre-approval to do the C-section (with a 48 hour wait time, of course)?

Ash January 29, 2010, 6:34 AM

I used to work for an insurance company and I cant stress enough how much info they have and don’t give you. On every plan there are a ton of things they don’t tell you and say its because its your company’s job to tell you. They will find every way to get out of it and have enough “small print” BS to keep them safe. They will say they sent you a letter about this and because they sent it they are in the clear if you read it or not is your own issue. And as an ex customer service rep they also make sure their employees are not telling you all the info so to be honest we are all screwed. Good Luck with everything - I think they only way you are going to win is if they pay it to keep you quiet - hope it all works out and they pay for this!!

michelle January 29, 2010, 8:48 AM

I really feel for you. I hope the negative publicity results in their covering the C-section. But I do think your story points to the need for nationalized, single-payer health insurance. You wrote:
“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.” But this is not possible under our current system. You are really arguing for a nationalized nonprofit healthcare system (correctly, I think), although you seem to shy away from saying this directly. A health insurance company is NOT in the business of providing insurance. It is in the business of underwriting — minimizing the amount it has to pay out in claims. This means that as long as we have the profit-driven system we have, insurance companies ARE going to make medical decisions for you, like it or not. If BCBS were to just pay for whatever procedures your doctor recommended, with transparency and accountability, they would never make money.

Lisakatherine9611 January 29, 2010, 9:27 AM

Unfortunatley, the MD who made the decision to perform the C-Section was unaware of the strict parameters for your insurance coverage. He or she could have documented the decision to deliver via C-section in a way that would insure coverage without lying and creating a fraud. It happens all the time in medicine

gbmonkey January 29, 2010, 11:30 AM

I agree the doctor should have documented the procedure as an absolutely necessary rather than patient opted for. If you were paying so much out of pocket already he should have known to word it correctly.

Elizabeth Langford - Chit Chat Mom January 29, 2010, 12:34 PM

The doctor did document it. BCBSAZ is saying that although the doctor documented the C-section as medically necessary… it doesn’t fit within BCBSAZ definition of “complications of pregnancy.”

BCBSAZ only approves C-sections that fall within 8 incredibly limited reasons for cesarean sections… fetal distress is not one them!

steph January 29, 2010, 5:06 PM

This story is a strong and powerful story for the issue of healthcare in our country. Its like in this country..we can think we have coverage but we may not if something doesnt fall into the specifics of the insurance company. I watched a special on tv a while back with Michael Moore and many insurance reps..and the whole discussion would always go back to the almighty dollar..not our health. I was going through a situation where my husband was not covered for an emergency room visit..due to my insurances definition of specific health issues that “defined” a reason for us to go to the emergency room…ended up having to pay out of pocket for the bill! Because they immediately wanted to send me to collections. Anyways…i hope and pray that you get your point across and are heard and get the results you want and deserve. Good luck! And right on for speaking out!

house music 2010 August 13, 2010, 10:44 PM

Sweedish house mafia should win the best dj award this year!

Steve Tirone September 7, 2010, 11:29 PM

good morning, I sent an web mail to you about this post, its not coming thru for me. Can you contact me when you get a chance.

eivai April 3, 2011, 7:54 AM

I was looking for this kind of review for about 1 hour.. i’m glad i found it. Great piece of work, continue it. Best Regards.


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