Do U.S. health insurance companies enjoy finding any odd reason to not cover you?
CLAIMANT: Peggy Robertson, 39, of Centennial, Colorado, was covered by her husband’s health plan…until he changed jobs in 2007. The family’s new carrier was Golden Rule, a subsidiary of UnitedHealth Group (the largest insurance company in the United States).
DENIED! Golden Rule deemed Robertson an “unacceptable risk” because her second child was born by cesarean section. According to Golden Rule, that increased the odds that she’d need to have a cesarean again, and they didn’t want to pay for it. The only condition under which they would cover her: If she agreed to be sterilized. “It makes no sense,” said Robertson. “I’m in perfect health.” U.S. Senator Barbara Mikulski (D–MD), speaking on her behalf, called Golden Rule’s policy “morally repugnant.”
OUTCOME: Robinson didn’t want to become sterile, so she opted out of the coverage.
CLAIMANTS: The Scaglione family of Lake of the Pines, California, applied for group family medical coverage in 2009.
DENIED! According to Blue Shield’s records, the mother, Valerie, suffered from a skin disease called rosacea. “I’ve never had that a day in my life,” she said. Blue Shield also claimed that one of her daughters, Samantha, once had bronchitis. That wasn’t true, either. Valerie figured it was a “glitch in the system” and asked Blue Shield to adjust their records. The company refused and, according to Valierie, wouldn’t say why.
OUTCOME: All five Scagliones—none of whom have any chronic illnesses—now collectively pay more than $2,000 per month for coverage. “That’s way more than our mortgage,” says Valerie. Anthony Wright, director of a consumer-advocacy group, said the Scagliones’ ordeal isn’t unusual: “We’ve seen people who have been denied health insurance for things as minor as heartburn. It’s getting to the point where living is a preexisting condition.”
Tree-climbing kangaroos can jump to the ground from the height of a five-story building.
CLAIMANT: One night in early 2008, a 45-year-old woman was at a bar in Fort Lauderdale, Florida, when a man that she had met there gave her a “knockout drug.” She awoke the next day fearing she may have been sexually assaulted. As a precaution, her doctor prescribed an anti-AIDS drug. A few months later, the woman applied for health coverage with a new provider.
DENIED! Upon seeing her medical records, the insurer assumed she had a preexisting condition—AIDS—and refused coverage.
OUTCOME: She was told she could reapply in four years, once it was clear that she was AIDS-free. Today she wonders whether she should have taken the medication in the first place: “I’m going to be penalized my whole life because of this.”
CLAIMANT: Six-year-old Madison Leuchtmann of Franklin County, Missouri, was born without ear canals. In November 2009, the kindergartner was about to outgrow a headband device that gave her very rudimentary hearing. Madison’s doctor said she needed permanent devices implanted inside her ears before she turned seven, or she may never be able to hear again. Cost of the implants: $20,000.
DENIED! Cigna HealthCare refused to pay for the implants, claiming, “Hearing-assisted devices are not medically necessary.”
OUTCOME: The Leuchtmanns are continuing to appeal the decision. As Madison’s doctor fumed, “This is obviously medically necessary. You have a child who has no ear canals!”
CLAIMANT: Jody Neal-Post, 52, applied for insurance with a new carrier. On the application form, she admitted that she’d previously received counseling and medical treatment, including a Valium prescription, to help cope with the emotional fallout from being abused by her ex-husband.
DENIED! Because of the counseling and treatment, the company ruled her too high a risk for them to insure. “I was just flabbergasted,” she said.
OUTCOME: Neal-Post happened to live in New Mexico, one of the few states with strict laws prohibiting insurers from denying coverage because of past domestic abuse. Neal-Post also happened to be an attorney, and she filed an official complaint with New Mexico’s Public Regulatory Commission. She got her coverage.
Japan’s All Nippon Airways asks passengers to use the restroom before boarding flights “to reduce carbon emissions.”
CLAIMANT: In 2007 Nataline Sarkisyan was 17 years old and suffering from leukemia. She received a bone-marrow transplant from her brother, but there were complications and her organs began to shut down. Doctors told her parents that she needed a liver transplant—soon—or she would die. Her doctors approved the request to put Nataline on a waiting list for a liver, pending her health insurer’s approval.
DENIED! After several days of deliberating, Cigna refused to cover the cost of the transplant because it was “outside the scope of the plan’s coverage” and Nataline had “little chance of surviving the procedure.” Her doctors appealed, claiming she had a 65-percent chance. Cigna still refused. Nine days after the initial request, Nataline’s family—along with 120 members of the California Nurses Association—protested at Cigna’s Glendale offices.
OUTCOME: While the demonstrators shouted outside, Cigna agreed to make a “one-time exception” and cover the costly procedure. But it was too late—before the operation began, Nataline died. Her family is currently embroiled in a legal battle against Cigna.
CLAIMANT: Rosalinda Miran-Ramirez woke up one night in 2009 to discover that her nightgown was covered with blood—because she was bleeding from her left nipple! Her husband rushed her to the emergency room, where doctors discovered a tumor and performed a biopsy. Thankfully, the tumor was benign.
DENIED! Blue Shield of California refused to pay the $2,791 emergency-room charges. The company insisted that Miran-Ramirez’s decision to go to the emergency room was “not reasonable” because her bleeding breast did not constitute a “real emergency.”
OUTCOME: Miran-Ramirez contacted a local television station, KPIX-TV in San Francisco, and told her story on the six o’clock news. “I am not a clinical person,” she said, “but if your breast is bleeding, for me that’s an emergency.” Amid all of the negative press, Blue Shield “reassessed the claim”…and covered the ER visit.