A California woman with a degenerative disc disease must pay for an artificial disk herself as her insurer, Blue Cross of California, has refused to pay for it as it is ‘experimental’. Protesters gathered outside of Blue Cross’s office in Costa Mesa, California earlier in the week to demand that the insurer reconsider the woman’s case.

Why the denial?

Blue Cross maintains that the artificial disk procedure is experimental and that it is waiting for additional testing to be completed and that the woman should have the more traditional spinal fusion treatment instead. However, that treatment would not allow her to do her job as a nurse. In addition, other insurers, such as Cigna, Kaiser and Aetna purportedly cover the ‘experimental’ treatment already – which doesn’t sit well policyholders.

Continually thinking ‘inside the box’

Denying coverage to those whose treatment doesn’t ‘fit in the box’ is not a new practice for Blue Cross according to consumer groups. In a similar situation, a teen was rushed to the hospital after he collapsed at a September football game in which he was playing. After being in a month long coma, he was gradually taken off his ventilator. According to his family, friends and his doctors, he continually made improvements in the hospital’s acute rehabilitation unit. However, Blue Cross didn’t think he’s making enough improvement to warrant the cost of remaining in the acute rehabilitation unit and wanted to move him to a lower level nursing center where he wouldn’t get the care he needed. All this after the teen’s doctors told Blue Cross that he needed to stay where he was.

Under fire – again

In addition to denying coverage, Blue Cross has come under fire recently for proactively asking doctors to assist them in rescinding insurance policies. The insurer had been sending doctors coverage letters and asking them to review patient data and compare it to the information given on the application for insurance. After being blasted by California’s Insurance Commissioner, Governor Schwarzenegger and a host of others, Blue Cross stopped the letter writing campaign.

If your insurance company has denied valid claims, it may be acting in bad faith. To discuss your situation with an attorney whose practice focuses in this area of the law, please click here. Consultations are free, without obligation and strictly confidential.