Page 1 of 2 1 2 LastLast
Results 1 to 10 of 11
  1. #1
    Join Date
    Dec 2009
    Posts
    5

    Default Denial of Infertility Coverage

    My question involves insurance law for the state of: MA
    Does anyone have any experience with fighting BLue Cross Blue Shield of MA with Infertiliy issues? I was denied infertity coverage when the FSH Blood test showed the numbers of 12, and 15 which indicated low ovarian reserve. I appealed and lost. I called BCBS and asked if I could switch infertility doctors and was told that it would be alright to do so. With the new doctor, my blood work -FSH was 6 and 6, far below any number associated with a low ovarian reserve. I was denied coverage anyways again. I'm appealing that decision presently. Does any one have an idea of what type of legal action I should be thinking of now?
    Thanks!
    Domcal

  2. #2
    Join Date
    Sep 2005
    Location
    Behind a Desk
    Posts
    98,846

    Default Re: Denial of Infertility Coverage

    Is it an ERISA plan? Have you read the language of the policy pertaining to infertility coverage and, if so, what does it say?

  3. #3
    Join Date
    Dec 2009
    Posts
    5

    Default Re: Denial of Infertility Coverage

    Quote Quoting Mr. Knowitall
    View Post
    Is it an ERISA plan? Have you read the language of the policy pertaining to infertility coverage and, if so, what does it say?
    Thank you for repying. Since I last logged on, I've filed another appeal and was denied again dispite my present FSH of 6 which according to BCBS's own coverage statement makes me coverageable. They simpy will not accept my present and current fertility health. Even thought the FSH blood test is the standard test that all doctors and insurance companies use as a measure of infertiliy. I"m not sure if BCBS is a ERISA or not. But I will look into that.
    Domcal

    Quote Quoting domcal
    View Post
    Thank you for repying. Since I last logged on, I've filed another appeal and was denied again dispite my present FSH of 6 which according to BCBS's own coverage statement makes me coverageable. They simpy will not accept my present and current fertility health. Even thought the FSH blood test is the standard test that all doctors and insurance companies use as a measure of infertiliy. I"m not sure if BCBS is a ERISA or not. But I will look into that.
    Domcal
    jsnjkdidns

  4. #4
    Join Date
    Jun 2006
    Location
    Massachusetts
    Posts
    24,390

    Default Re: Denial of Infertility Coverage

    ERISA has nothing to do with the carrier. It has to do with whether your plan is through your employer or not. Virtually all employer-sponsored plans, with any carrier, are ERISA plans.

    To answer your question I need you to find out what state's laws your plan is written under. Assuming this is an employer-sponsored plan, you can find this information in your SPD (summary plan description). Your employer is required by law to give you a copy if you ask. It may or may not be the state where you live, unless every single location of your employer is within the same state.

    If this is not an employer sponsored plan, then the state laws that apply will be the state that you live in.

    If you can confirm that much for me, I can help you further.

  5. #5
    Join Date
    Apr 2007
    Location
    Il.(near StL,Mo.)
    Posts
    5,252

    Default Re: Denial of Infertility Coverage

    Let's ask it this way -Is this an individual health ins. policy as opposed to a group health ins. policy through your employer?

    PS -cbg, you & I submitted our replies off at the exact same time.

  6. #6
    Join Date
    Dec 2009
    Posts
    5

    Default Re: Denial of Infertility Coverage

    Hi thanks for your reply. This is an individual health ins policy that is from my husbands employer in MA. And we live in Ma also. I should be covered now as my FSH level is far below their coverage limit but my insurance plan wont recognize my current/present FSH (FSH level-which is the standard for all insurance/doctors for determining eligibility) but will only recognize my past FSH level which was above their cut off FSH number.
    I hope that this helps you, help me
    Domcal

  7. #7
    Join Date
    Jun 2006
    Location
    Massachusetts
    Posts
    24,390

    Default Re: Denial of Infertility Coverage

    If it is from your husband's employer, it is not an individual policy; it is a group policy. There is a reason I am making this distinction and it is quite important. Does the employer pay part or all of the premium? Do you have any control over changes to the policy? Can you decide when to change the deductible or add riders to the policy, or does the employer do that?

    Is EVERY SINGLE LOCATION of your husband's employer inside MA? I don't mean, the location your husband works; I mean EVERY location where ANY employee of this employer works.

    There is a reason for these questions; it makes a difference.

  8. #8
    Join Date
    Dec 2009
    Posts
    5

    Default Re: Denial of Infertility Coverage

    Quote Quoting cbg
    View Post
    If it is from your husband's employer, it is not an individual policy; it is a group policy. There is a reason I am making this distinction and it is quite important. Does the employer pay part or all of the premium? Do you have any control over changes to the policy? Can you decide when to change the deductible or add riders to the policy, or does the employer do that?

    Is EVERY SINGLE LOCATION of your husband's employer inside MA? I don't mean, the location your husband works; I mean EVERY location where ANY employee of this employer works.

    There is a reason for these questions; it makes a difference.
    HI, thanks again for your reply! Yes it is a group policy and the employer does pay part of the premium, and the company does have some work sites in NH.
    I don't beleive that empoyees have rights as far as control over changes to the policy or deciding when to change the deductible or add riders to the policy. But I will confirm that asap.
    Thanks again
    Domcal

  9. #9
    Join Date
    Jun 2006
    Location
    Massachusetts
    Posts
    24,390

    Default Re: Denial of Infertility Coverage

    Okay, based on what you have told me, this is what I need to know:

    Is the policy written out of MA, or NH? Given what you have told me, it could be either. The first page of the Summary Plan Document will say.

    Since it is a group policy, I already know that employees have no authority to make changes. That was initally unclear, but it is now.

    The other thing I need to know, and you'll have to ask HR this one (it won't say in the SPD) is whether the plan is self-insured or fully insured. HR will know what I mean by that.

  10. #10
    Join Date
    Dec 2009
    Posts
    5

    Default Re: Denial of Infertility Coverage

    Quote Quoting cbg
    View Post
    Okay, based on what you have told me, this is what I need to know:

    Is the policy written out of MA, or NH? Given what you have told me, it could be either. The first page of the Summary Plan Document will say.

    Since it is a group policy, I already know that employees have no authority to make changes. That was initally unclear, but it is now.

    The other thing I need to know, and you'll have to ask HR this one (it won't say in the SPD) is whether the plan is self-insured or fully insured. HR will know what I mean by that.

    Hi again, it is are fully insured. Greater than 50. It is written in Mass.
    Domcal

    1. Sponsored Links
       

Page 1 of 2 1 2 LastLast

Similar Threads

  1. Health Insurance: Possible Denial of Insurance Coverage Due to a Pre-Existing Condition
    By jnes in forum Insurance Law
    Replies: 9
    Last Post: 03-28-2011, 11:47 AM
  2. Medical Malpractice: Denial of Follow-Up Due to Losing Medical Coverage
    By arthurrd in forum Malpractice Law
    Replies: 4
    Last Post: 03-26-2010, 02:22 AM
  3. Other Insurance: Denial of Insurance Coverage Due to Wrong Application Form
    By dani808 in forum Insurance Law
    Replies: 2
    Last Post: 03-08-2009, 03:53 AM
  4. What Do You Do About Denial Of Coverage?
    By jaspereinstien in forum Worker's Compensation
    Replies: 3
    Last Post: 11-08-2008, 08:14 PM
  5. Repossession: Denial of Disability Coverage from ATV Purchase
    By SassyCathy in forum Cars and Dealerships
    Replies: 1
    Last Post: 11-13-2006, 03:05 PM
 
 
Sponsored Links

Legal Help, Information and Resources