I have health insurance with Blue Cross Blue Shield (BCBS) of Illinois, which I get through my employer. The certificate of coverage states that ER visits have a $50 copay which is waived if you are admitted. I came down with a severe case of the flu late at night and needed to go to the ER. Due to physical symptoms I was having, I was unable to walk on my own, and my roommate called an ambulance for me. The paramedics would only take me to the nearest ER, which was not part of my HMO. According to BCBS's rules, I can go to any ER and receive treatment, but if I need to be admitted, they have to transfer me to one of my HMO's hospitals. The ER treated me but wanted to admit me for observation because I was slow to respond to the treatment. They paged my doctor who instructed them to have me transfered to my hospital. They made the arrangements and an ambulance took me there. I was immediately taken to my room where I saw a doctor and stayed until the next afternoon when I was well enough to be released.
I immediately called BCBS as instructed and informed them that I had been treated at an out of network ER and had then been transferred to my hospital for inpatient treatment. The woman on the phone stated that since I was admitted, my co-pay would be waived and I would not have to pay anything for my treatment. About 2 weeks later I got my explanation of benefits (EOB) from BCBS for both the ER visit and the inpatient stay. The inpatient one showed that everything was covered, as expected, the the ER one showed that I would owe a $50 copay. I called them to find out why, because I had been admitted and it should have been waived, as I was originally informed, and the man on the phone stated that when the ER's EOB was prepared, the claim from my hospital had not yet been finalized, so the copay still showed up. He stated that he went into the computer system and manually waived the copay and that I would not be charged $50. However, less than 24 hours later I got a voicemail from someone else at BCBS stating that the guy I talked to had made a mistake and that I would have to pay the copay. I again called to find out why and was told that it was because I was never actually admitted to my hospital. I told them that was wrong, I had been admitted. The woman stated that I would have to contact the hospital and have them resubmit my billing.
I did so, and got another letter from BCBS stating that I would still have to pay the copay. At this point, I filed an official appeal with them giving them a copy of my discharge papers from the hospital showing that I had been admitted. About two weeks later I got a letter from them stating that my appeal was denied and I still had to pay the $50 copay, but they changed their reason. This time they said that it was because I was admitted for less than 24 hours. However, this loophole is not mentioned anywhere in my certificate of coverage. I then filed a complaint with the State of Illinois' Department of Insurance Regulation. They inquired as to why I was being charged the copay, and this time BCBS blatantly lied to them and told them it was because the ER visit and the inpatient treatment were two separate events. They told the investigator that I discharged myself from the ER and then made my way to my own hospital and went to their ER and was admitted from there. Therefore, they claimed that I should have been charged to ER copays, and they waived the second one because I was admitted from that visit. The state accepted their explanation and dropped the case. However, their explanation is a complete lie. I did not discharge myself from the first ER. I was transferred, by ambulance, which BCBS paid for, to my hospital and was immediately taken to my room. I was never in my hospital's ER.
At this point, I had no other options other than taking BCBS to court, which would cost way more than the $50 I was being charged by the ER, so I just paid the copay. However, it is obvious that BCBS is an extremely dishonest company that nickel and dimes their customers and blatantly lies and forges documents to get out of paying any amount they can. I am absolutely furious that I have been paying premiums every month for this coverage and they then refuse to provide all of the benefits I have been paying for. I am currently advocating to my employer to change health insurance providers. The only way BCBS will learn is if their actions start having consequences.
Greg
Chicago, Illinois
U.S.A.
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