I have an individual policy with Blue Cross and Blue Shield. When I first obtained the policy (after a switch in employment), I was given a book showing all of the doctors covered under my policy. I was happy to see that my thearapist was one of them and continued my thearpy with her. After the first session I receieved a letter from BCBS stating that my coverage did not include mental health issues (since I had only an individual policy and not a group policy) so they would not cover my bills. After extensive complaints and appeals they admitted that they sent me the wrong book for my policy which had stated that this doctor was covered by them and I was basically out of luck and ended up having to pay the bill myself. Can an insurance company really deny you mental health coverage? Isn't this a form of discrimination? I can't even see the doctor for depression without them denying my claim. What is wrong with this picture?
2007-08-13 09:11:03 · 10 answers · asked by MelA 2 in Business & Finance ➔ Insurance
A provider directory (which is what I'm assuming that you are referring to) is not a contract with you. Its a just list of all of the medical practitioners who have signed a contract with Blue Cross to provide services for the people who happen to have coverage for that service under their policy.
Your policy manual is what dictates your own specific coverage...not the provider directory. Just because your therapist happens to have signed a contract with Blue Cross doesn't mean that YOU have coverage for her service...always, always, always refer to your policy, not the provider directory to figure out what's covered for you.
Unfortunately, it was your error to refer to the general provider directory and not your specific policy...there is no legal recourse on your end for this.
(If they had sent you the wrong policy document itself...the document that spells out what your copays are, what's included and excluded, etc...then you would likely be able to get your claims covered. But if it was just the provider directory...nothing you can do about that.)
2007-08-13 16:40:00 · answer #1 · answered by sarah314 6 · 0⤊ 0⤋
When you say "switch in employment" did you mean to another company sponsored plan? If so, that IS Group Coverage and not Individual. If you signed up for the coverage on the pretext of the booklet they had sent you, and were then told they provided you with the wrong information, that is "bait and switch" and I would sue in a heart beat. If it is individual insurance there should be some form of Buy Up coverage that would allow you to purchase Mental Health Coverage for an additional fee. However, Blue Cross is a multimillion dollar insurance agency and should not be making mistakes like sending out wrong booklets to their insureds. I would recommend switching carriers if you have the choice.
2007-08-13 11:37:12 · answer #2 · answered by Katie S 2 · 0⤊ 0⤋
Many individual insurance policies don't cover mental/nervous treatment. You typically have to purchase that coverage in the form of a "rider".
No, it's not discrimination. When you buy an individual policy, you buy a lot of services ala carte. Maternity is a good example - coverage is not typically included, so if you want it, you buy it separately. Mental/nervous coverage is the same way.
You can sue them, but why? They haven't done anything wrong. You should've double-checked to make sure your policy included all the benefits you need.
2007-08-15 07:46:08 · answer #3 · answered by Christie 4 · 0⤊ 0⤋
policies and coverages are regulated by your state [I assume you're an American, correct?].
if the state does not require them to cover mental health issues, they won't.
***
from the viewpoint of the insurance company, it is very simple. if mental health coverage isn't required on all policies in some group [all individual policies collectively are one group], they offer it on none.
the reason is plain ... only people who expect to need the coverage would pay extra to get it and thus the amount the company would need to charge would be approximately the same as the amount of your bills -- I'm guessing that to be on the order of 400 to 500 a month extra.
as to receiving the wrong book prior to signing up ... your case would legally be one where both you and they made a mistake ... they mistaken sent you the wrong book and you mistakenly agreed to coverage thinking the policy included your provider even though the policy language almost certainly says 'not covered' under outpatient mental health services.
that is called 'mutual mistake of fact' in the courts and results in both parties being returned to their original state of affairs (as much as possible) -- in other words, you'd still have no coverage for this.
sorry to say, about all you can do is write your Legislators. No one else can change your state's laws.
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2007-08-13 09:19:19 · answer #4 · answered by Spock (rhp) 7 · 0⤊ 0⤋
Here in the US, you can sue anyone for anything.
You'll have to pay your lawyer up front, you'll lose, and you'll have to pay their lawyer, also.
Your CONTRACT states what they have to cover, and what they don't have to cover. Yes, they don't have to cover EVERYTHING. Many private policies do not cover mental health.
Yes, insurance is ALL ABOUT discrimination. That's why 16 year old boys pay more for their car insurance.
Whenever you are going to use a health service, it's up to YOU to call the number at the back of your card, and verify if you've got coverage, and verify that your provider is STILL in network with them.
Sorry. Not what you want to hear, I'm sure.
2007-08-13 09:51:03 · answer #5 · answered by Anonymous 7 · 1⤊ 0⤋
The best you could do - with no small amount of trouble - is get them to cover costs you inucrred before you got the right handbook.
The underwriters determine your premiums based on two facts: risk exposure and breadth of coverage. Want a plan that covers mental health issues? Find a provider that offers it...but expect to pay more - ESPECIALLY if you've shown you will be utilizing it regularly.
The underwriter's job is to make sure that the costs you incur don't rise above 60% of your paid premium (the other 40% goes to paying administration costs). They would never make money if they paid out as much (or more) as you pay in.
Would it be discrimination to not offer insurance to a terminally ill patient? No. Would it be a wise risk for the insurance company to take? Absolutely not!
2007-08-13 09:23:45 · answer #6 · answered by David V 6 · 1⤊ 0⤋
Apparently the health insurance policy you purchased does not provide coverage for mental health issues. As such, you did not pay premium for mental health coverage - you did not pay for that service. This is not discrimination.
Discrimination would be refusing to sell you a policy because of your skin color.
2007-08-13 12:13:34 · answer #7 · answered by Boots 7 · 0⤊ 0⤋
Different policies cover different problems. It's not discrimination. Forgetting the book listing the doctors, didn't you get a writeup showing what services were covered? That would be the list that would be the legal contract.
2007-08-13 09:29:44 · answer #8 · answered by Judy 7 · 0⤊ 0⤋
if you didn't read the fine print, that's not their fault. read over your coverage, and if you find that they should cover it, file a claim in person if possible. check with your doctor to make sure that they are still on BCBS, with their services. if not, then that's why it wasn't covered. it happens all the time. doctors drop in and out all the time.
2007-08-13 09:30:24 · answer #9 · answered by Anonymous · 0⤊ 0⤋
There is an Insurance Commissioner that is over these companies. Get in touch with them and tell them your story...It's worth a try. good luck...bettyk
2007-08-16 17:55:40 · answer #10 · answered by elisayn 5 · 0⤊ 0⤋