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Report: #170729

Complaint Review: Blue Cross Blue Shield Of Illinois - Chicago Illinois

  • Submitted:
  • Updated:
  • Reported By: Chicago Illinois
  • Blue Cross Blue Shield Of Illinois PO Box 1364 Chicago, Illinois U.S.A.

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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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This report was posted on Ripoff Report on 01/06/2006 03:35 PM and is a permanent record located here: https://www.ripoffreport.com/reports/blue-cross-blue-shield-of-illinois/chicago-illinois-60690/blue-cross-blue-shield-of-illinois-ripoff-does-not-provide-benefitscoverage-you-pay-for-c-170729. The posting time indicated is Arizona local time. Arizona does not observe daylight savings so the post time may be Mountain or Pacific depending on the time of year. Ripoff Report has an exclusive license to this report. It may not be copied without the written permission of Ripoff Report. READ: Foreign websites steal our content

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REBUTTALS & REPLIES:
0Author
8Consumer
0Employee/Owner

#8 UPDATE Employee

read your policy

AUTHOR: Andrea - (U.S.A.)

POSTED: Wednesday, March 15, 2006
You state that the er copay is waived if admitted. You do understand that once you are admitted, you now have your Inpatient copay (which is usually more than 2x the er copay)? You state your appeal was denied....you made out then. You ended up with the lesser of the 2 copays. Most HMO plans carry 50.00 er and 400.00 hospital copays. The rep can always go back and take back the er copay and apply the hospital copay instead...Sometimes it is better to keep your mouth shut on such things because when you look at the whole scope of things, you have it pretty good.
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#7 Consumer Suggestion

the problem is there are two claims

AUTHOR: Lisa - (U.S.A.)

POSTED: Saturday, January 07, 2006
I work as a phone rep for an insurance company (not BCBS, one of their competitors) the reason that the copay was not waved is because there are two claims. The first claim is for the hospital you were seen in the er which only has an er charge, the second is from a completely different hospital for the inpatient stay. Chances are the first claim was processed before the inpatient claim which caused the processor to apply the copay based on the charges listed on that claim. I would contact your carrier and ask the representative to send the er claim back to a processor along with the inpatient charges so that the processor can see you were admitted to the hospital and perhaps get your $50 reimbursed, if necessary speak to a manager. Good Luck!
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#6 Consumer Suggestion

Robert you are insensitive and foolish

AUTHOR: Lee - (Australia)

POSTED: Saturday, January 07, 2006
So a consumer takes out an insurance policy and is issued a certificate that states no $50 copay if admitted to hospital, consumer is admitted to hospital and insurance company dictates $50 copay is to be made. What bloody good is the certificate? Yeah Robert so they paid the main medical expenses, so what, its not the entire kit and kaboodle, are you suggesting the consumer should be "happy" that most of the claim was paid when in fact he is entitled to it being paid 100%, where does this reasoning come from? This is the type of story that really drives sensible people away from a company, I for one would have done everything this guy did, all the appeals, all the letters, all the complaints at least you are guaranteed to have monopolized several BCBS staff members time for days in their responding to appeals, getting authority to send letters etc., this surely cost BCBS more than $50 in lost productivity and is another shining example of how insurance companies will not spare any expense (even expenses 100x greater than what a consumer is questioning) to strike an appeal down. So Greg good on you for going through all the motions with this corporate monster, people like you who keep companies honest are few and far between. Robert maybe you should be prepared for somthing similar to happen to you and accept it, like having an insurance certificate that says you are covered for all medicines deemed medically necessary than having your claim denied because BCBS disagrees with your doctor.Gee, I guess as long as they pay something you'll be content, absurd.
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#5 Author of original report

It's the Principle

AUTHOR: Greg - (U.S.A.)

POSTED: Friday, January 06, 2006
I am the first to be grateful for what BCBS did cover. The whole experience was very traumatic and I was glad to not have to worry about paying for it on top of everything else. However, I am still angry about being lied to multiple times and that they would not provide the full benefits that I paid for. It wouldn't matter if it was just the $50 here or the entire claim. They were supposed to cover all of it and they did not. While $50 may seem trivial, it makes me wonder if this had been a bigger claim, what else would they have reneged on? If they can't be honest with the little things, they're definitely not going to be honest with the bigger things. Their multiple lies and failure to live up to their obligations says something about the type of people running this business. Fortunately (for me anyways, not so much for them), karma's a B**** and I will enjoy watching their fall when their lies, deceptions, and unethical practices bring them down.
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#4 Author of original report

It's the Principle

AUTHOR: Greg - (U.S.A.)

POSTED: Friday, January 06, 2006
I am the first to be grateful for what BCBS did cover. The whole experience was very traumatic and I was glad to not have to worry about paying for it on top of everything else. However, I am still angry about being lied to multiple times and that they would not provide the full benefits that I paid for. It wouldn't matter if it was just the $50 here or the entire claim. They were supposed to cover all of it and they did not. While $50 may seem trivial, it makes me wonder if this had been a bigger claim, what else would they have reneged on? If they can't be honest with the little things, they're definitely not going to be honest with the bigger things. Their multiple lies and failure to live up to their obligations says something about the type of people running this business. Fortunately (for me anyways, not so much for them), karma's a B**** and I will enjoy watching their fall when their lies, deceptions, and unethical practices bring them down.
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#3 Author of original report

It's the Principle

AUTHOR: Greg - (U.S.A.)

POSTED: Friday, January 06, 2006
I am the first to be grateful for what BCBS did cover. The whole experience was very traumatic and I was glad to not have to worry about paying for it on top of everything else. However, I am still angry about being lied to multiple times and that they would not provide the full benefits that I paid for. It wouldn't matter if it was just the $50 here or the entire claim. They were supposed to cover all of it and they did not. While $50 may seem trivial, it makes me wonder if this had been a bigger claim, what else would they have reneged on? If they can't be honest with the little things, they're definitely not going to be honest with the bigger things. Their multiple lies and failure to live up to their obligations says something about the type of people running this business. Fortunately (for me anyways, not so much for them), karma's a B**** and I will enjoy watching their fall when their lies, deceptions, and unethical practices bring them down.
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#2 Author of original report

It's the Principle

AUTHOR: Greg - (U.S.A.)

POSTED: Friday, January 06, 2006
I am the first to be grateful for what BCBS did cover. The whole experience was very traumatic and I was glad to not have to worry about paying for it on top of everything else. However, I am still angry about being lied to multiple times and that they would not provide the full benefits that I paid for. It wouldn't matter if it was just the $50 here or the entire claim. They were supposed to cover all of it and they did not. While $50 may seem trivial, it makes me wonder if this had been a bigger claim, what else would they have reneged on? If they can't be honest with the little things, they're definitely not going to be honest with the bigger things. Their multiple lies and failure to live up to their obligations says something about the type of people running this business. Fortunately (for me anyways, not so much for them), karma's a B**** and I will enjoy watching their fall when their lies, deceptions, and unethical practices bring them down.
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#1 Consumer Comment

Life is too short!

AUTHOR: Robert - (U.S.A.)

POSTED: Friday, January 06, 2006
Are you kidding me? You got coverage on thousands of dollars of medical help and you are crying over $50!

Maybe you should sit back and re-read your post and see how stupid it sounds. I bet there are many people in this country that would gladly pay $50 to have health coverage like Blue Cross.

I got it, why don't you post again asking if anyone would like to start a class action lawsuit because of the dishonestly of Blue Cross!

I have 3 words for you...... GET OVER IT!


I just wanted to thank you for keeping me entertained on a boring Friday.
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