BlueCross BlueShield of Maryland Reverses Denial of $160K Health Insurance Claim

While our politicians debate the merits of the Affordable Care Act (a.k.a. “Obamacare”), insurers continue to deny health insurance claims by the thousands every year. These denials often saddle consumers with outsized medical debts they cannot afford.

As a former Senior Counsel to the Maryland Insurance Administration and now an attorney in private practice, I have been receiving an increasing number of calls from individuals facing personal financial crises caused by health insurance claim denials. Unfortunately, there is a real difference between obtaining a health insurance policy and forcing the insurer to provide coverage when you need it most.

Large claim denials can devastate a family’s finances and add to the stress caused by serious illness or injury. Some of my clients have been stuck with six-figure medical bills and forced to fight their insurance company even while struggling to regain their health. Fortunately, when insurance claims are improperly denied, policy holders do have options. They can often force their insurers to reverse their initial denials and provide coverage.

A case in point: I recently convinced BlueCross BlueShield of Maryland to withdraw voluntarily a denial of coverage for a $160,000 microprocessor-controlled “Genium” prosthetic knee. 

My client had been in a terrible automobile-related accident and had lost one leg. The client works for a veterinarian, and the job involves lifting and handling large dogs, often weighing more than one hundred pounds. The client also lives at the top of a hill and cuts wood to heat the family home.

This individual tried the ordinary prosthetic knee that BlueCross BlueShield agreed to pay for, but the knee wasn’t functional. It would lock when my client was lifting large dogs, and during attempts to travel to and from the family home. After multiple falls, including a fracture and dislocation of the left shoulder, my client switched to the special, microprocessor controlled “Genium” knee, which helped a great deal. With the Genium Knee, my client could perform work duties and travel to and from home, without assistance and without falling. Problem solved – that is, until BlueCross BlueShield of Maryland created a new one.

The insurer denied coverage for the Genium knee because it was allegedly not “medically necessary.” As strange as it sounds, the insurer’s position was that it was not “medically necessary” for the client to have a knee that allowed performance of work duties and safe travel to and from home.

When my client appealed this denial, BlueCross BlueShield obtained a “peer review” opinion from a doctor who confirmed the denial, despite a contrary opinion from the client’s treating doctor at Johns Hopkins. In my experience, these “peer reviews” seem to be nothing more than superficial rubber stamps of the health insurer’s position.

In this case, as in others, the peer-reviewing doctor was anonymous. The doctor had never treated my client, and in fact worked for a company that BlueCross BlueShield hires to conduct peer reviews. Not surprisingly, the doctor listed “CareFirst BCBS” as his/her “client” on the “peer review” form – not the patient. The doctor simply stated a superficial conclusion that was advantageous to the health insurer. The contrary opinion of the treating Johns Hopkins doctor apparently made no difference. This practice of using non-treating, anonymous “peer reviewers” to confirm denials of health claims is not limited to BlueCross Blue Shield.

I am currently involved in a different case where United Healthcare Insurance Company similarly retained an anonymous, non-treating “peer reviewer” to rubber stamp its denial, despite the fact that he/she had never even met or talked to my client, and despite contrary opinions from actual treating doctors. In my view, these “peer reviews” are worthless, and do not provide a valid basis for a health insurer to “confirm” the denial of a claim.

In my Genium knee case, my client filed a complaint with the Maryland Insurance Administration, and then hired me to assist. I drafted a detailed letter to the Administration explaining the deficiencies in BlueCross BlueShield’s analysis, and in the superficial “confirmation” of the anonymous peer reviewer. After receipt of my letter, BlueCross BlueShield of Maryland simply withdrew its denial, and agreed to pay for the $160,000 Genium knee.

While I am pleased for my client, this “victory” came at a cost. Doing battle against insurance companies can be time-consuming and draining. In addition, the Maryland Insurance Administration did not force the insurer to pay attorney fees. My client paid that cost only in the face of less appealing alternatives: pay a $160,000 bill for the knee out of pocket, or revert back to the unworkable knee.

Sadly, nothing about this case incentivizes BlueCross BlueShield to pay valid claims promptly in the future. In fact, the current system provides financial disincentives for paying large claims. If my client had not had the resources to pay my bills, BlueCross BlueShield may have “saved” $160,000.

If the individual fights back, the insurer can just honor its contractual obligation to pay the claim, as BlueCross BlueShield agreed to do. There is no financial penalty for forcing a patient to file an appeal and administrative complaint, and to hire an attorney to argue for coverage. BlueCross BlueShield simply folded its tent, paid the claim, and the Administration closed its file.

The Maryland General Assembly could help fix this problem by passing a statute that truly penalizes insurers who deny valid claims. In my next post, I will detail the scope of such a statute and what it could achieve.

In the meantime, if you are facing similar issues, and would like assistance in addressing your insurance questions, or in reviewing your current coverage, feel free to contact me, Alex J. Brown, at Shapiro Sher Guinot & Sandler, P.A. and Chairman of the firm’s Insurance Practice Group, at 410-385-4220, or by email at ajb@shapirosher.com.