I wrote about fighting Blue Shield before here and here. This is Round Three (and unfortunately, not the last). As a lawyer, I bill my life in 0.1 increments or 6 minutes. The number in parenthesis denotes the time I lost. 

There is one thing I do miss about having a fluorescent light office job – health insurance. When I worked for the State, or Big Law, I always had group policies. Typically, these insurances will cover everything with a minimal copay. Now that I am self-employed, I no longer enjoy such policy.

My husband and I purchase our own individual policy from Blue Shield/ Blue Cross California. We have health and dental coverage. Since I’m a lawyer and I’m slightly paranoid about becoming my own bankruptcy client because we can’t pay our medical bills, I actually read our coverage – cover to cover. (You should too.) I have a good idea of what is covered and what is not.

About a month ago, I went to the dentist for a new Occlusal guard (fancy term for night guard). My dentist says she will get a preauthorization. Great. 

Few weeks later, I receive an “Explanation of Dental Plan Reimbursement” and guess what it says? DP2 Service denied. Does not meet the frequency requirements of the plan. (Review of letter 0.1)

I call Blue Shield and the rep tells me I qualify for an Occlusal guard once every FIVE years. Now, for those of you that don’t get to experience the joys of wearing a night guard 365 days a year, let me explain: imagine sticking in the same plastic device in your mouth everyday for five years. There is NO WAY in HELL this is happening. That’s just gross.

I explain to the rep that according to page 19 of the policy, paragraph 3, subsection c) under General Limitations, it states “One in twenty-four (24 months): Occlusal guards.” She says “I don’t look at the policy. I punch in the treatment code and look at what the screen tells me.” Of course. (Telephone call to Blue Shield 0.4)

I then complete the Grievance Form to fight for what I’m paying for and what Blue Shield promised, in writing to deliver: f****** night guard, once every two years.

I angrily rip out the page from the policy (Ripping out policy 0.1), download the Grievance Form, scan their denial letter, and write my letter. (Draft letter 0.5, printing and postage cost $2.50). A month later, to my delight, Blue Shield has kindly decided to pay for the Occlusal guard. This time, I didn’t have to appeal it to the California Department of Insurance.

Now, you might be wondering, why are you still so angry? You won!!! Well, not really. It’s hardly a “win” to have to fight to get what you are paying for and what is clearly provided for under the contract. What also bothers me is the fact that most Blue Shield customers probably haven’t read the policy so chances are, they would’ve just accepted the denial of coverage.

Yes, I know, it’s $450. But what if it had been $4,500? Or $450,000? If it takes me 1 hour to dispute a $450 procedure, how long will it take to dispute a $450,000 procedure? What if it’s not an Occlusal guard but brain surgery? I have to write dispute letters for every procedure Blue Shield denies? Really?

This issue with health insurance coverage was very well outlined in the recent Time Magazine article “Bitter Pill: Why Medical bills Are Killing Us.” Go read it. Or maybe don’t read it. It will make you lose sleep at night – not at the thought going to the hospital but the bills that follow it.

For your viewing pleasure, I uploaded my dispute letter and their response to docstoc // Blue Shield Coverage Denial Dispute –

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