Denial of coverage for covered service

[Due in a month]

What is the name of your state (only U.S. law)? California

We have an EPO that has in-network coverage only, no out-of-network. For services that are covered without an in-network provider/facility within 30 miles of the patient's home, a "gap extension" is to be applied for to cover an out-of-network provider/facility at the in-network rate to provide the covered service.

This is according to our insurance company.

A couple months ago we switched care to a midwife as doctors kept trying to push me into an early delivery with c-section without medical indication either is necessary, just as a "preventative" measure. I do not believe in unnecessary surgical procedures, and the pressure had be crying most nights afraid I'd be forced into one (I have found cases of women forced into them against their wills on emergency court orders including once case where mother and baby both died).

So we verified with our insurance company that midwives and birth centers are a covered benefit (both are), as well as a midwife for a homebirth delivery (yes), were told to set up an initial appointment and begin care with a midwife and to apply for gap extension, which we did.

Last Wednesday, with only a month to go until the beginning of the time frame for anticipated delivery, we received a denial letter for gap coverage.

This letter lists the midwife as a doctor, which I have verified with the state licensing board is incorrect. She is not a doctor. She is a certified nurse midwife. The letter states,

"Here are some physicians, facilities, or other health care professionals in this specialty who are part of your plan's network."

Of the two listed, one works with no midwives, and I actually had to explain to the person I spoke with what a midwife even is. The other has a midwife on staff who delivers at the local hospital ONLY.

On these grounds, they are denying me gap extension coverage for a midwife-attended homebirth as well as for a birth center birth, despite these things being covered benefits, essentially advertising benefits they will not, in practice, actually cover. Part of the reason we did go with this insurance company is birth center ad homebirth midwifery coverage. It is not open enrollment, we can not change to another health plan. We were suckered into this plan on false grounds.

We've been told to file an appeal, though it's very possible, to the point of likely, that the baby will be born before there is any resolution. If we continue with our midwife after receiving this letter, there is the possibility they will deny covering anyway for lack of pre-authorization.

We need to know - URGENTLY - if an insurance company is allowed to deny coverage for explicitly-covered services (midwife coverage for homebirths and birth centers) like this, on the grounds that there are doctors and a single midwife who delivers at the hospital. We have very little time to make a back-up plan, can not afford the midwifery delivery fee out of pocket, and absolutely refuse to deliver at the place where the doctors already pressured me so hard to have an early delivery and c-section.

Or are they required to follow through with covering our midwife for a homebirth or birth center as this is a clearly-stated benefit with no one in-network who provides it?

If our only option is indeed an appeal, if we manage to get them to approve it, say, three months from now, would they be required to cover retroactively to the date of the appeal, and to reimburse for our expenses?

Any law codes that could be provided would be so very much appreciated. The stress this has caused me and the sleepless nights has resulted in a 4-pound weight loss in the last five days. I shouldn't be crying from the anxiety of now not knowing how or where my baby will be delivered, if I'm going to be forced t birth at a hospital where I'll be pressured, if not outright forced, into a c-section, or what will happen. Things were calm for us, we were comfortable with our choice of delivery, and now we know absolutely nothing at all, and this baby is our sixth, the only one to make it past eight weeks. The joy of pregnancy is now overshadowed by stress and anxiety. We don't know what to do at this point. We will NOT go to a hospital!! That is NOT what either of us want, and no one should be trying to force me!!

[ecmst12]

This will be governed by the policy only. The law does not have much to say about it. You might be better off finding a doctor that will attend you at the birth center, or going with the midwife at the hospital. You can also get a doula that can help advocate for your wishes in the delivery room, I don't think they are too expensive.

Changing practitioners this late in your pregnancy wasn't the greatest idea to begin with though.

[Due in a month]

Driving 400 miles each way to continue seeing my old provider isn't very feasible, is it? My husband was transferred. If we wanted him to have a job and for us to have medical coverage, we had to go. This is not a great economy to be without work.

The hospital-midwife won't take a pregnant woman so close to the due date. No doctors can be found at birth centers, nor will the insurance company extent gap to cover a birth center anyway.

A doula in this are is in the range of $2,000. We do not have $2,000, or even half that. We do not have assets at this point with any value, aside from a car worth about $800 that my husband uses to get to and from work.

What does the law say about offering a service, only to deny covering it? Is this not some sort of legal bait-and-switch? Does "truth in advertising" or something similar not apply here? On top of this, I have the names of every person I have spoken with verifying time and again that midwives attending home births and birth centers are covered benefits, and that gap exception is provided if there are no in-network providers within 30 miles. Eight people from the insurance company have verified this to be correct. And now with technically less than a month to go, the insurance company is saying that no, they won't cover what is a covered benefit. Are you REALLY saying they're allowed to pull this bait-and-switch crap and force me into a hospital?

I would have this baby at home unattended before going to a hospital and being pressured and coerced into doing it the way a stranger wants it. My small intestine is in FRONT of my uterus. A stranger cutting into me is extremely dangerous. It would be risking my life, literally, to do what the insurance company is trying to force me to do.

[ecmst12]

What they are probably going to say is that if there is a network provider that provides the service (delivering baby) in the area, then you have to use them. This is a contractual issue, not regulated by statute. Read the policy.

Please watch your language, this is a G rated site.

[Due in a month]

They've confirmed, repeatedly, that birth centers and midwife-attended home births are covered services. In the denial letter, they're claiming she's a doctor. I've verified with the state board of licensing she is not. I've verified as well that, specifically, birth centers are covered, and there is not one in-network in this area.

They've gone back and forth between insisting my midwife is actually a doctor (I'm going to take the state's word that she's not over theirs that she is), and saying that there's a midwife available to provide the birth-center or home birth, which there isn't. The name they gave me is to someone not taking patients and who only works at the hospital.

One of the supervisors I've spoken with as well as three of the four customer service reps I've spoken with since getting this denial letter had admitted to be dumbfounded as to why this isn't being covered. So it's not just me reading it as home birth-midwives and birth centers being covered and now being denied.

Nowhere in the policy does it state simply "delivery is covered with these following choices," or anything to that effect. Nowhere does it exempt a midwife or birth center if a doctor and a hospital are in-network. It states midwives for home delivery, midwives for birthing centers, doctors, and hospitals, all as separate covered benefits.

[ecmst12]

Did you send them a letter from the in-network midwife showing that she is not taking new patients now?

[lya]

I believe the problem may be with the insured's decision to act against medical advice and change to a midwife, who will have to send the patient to a physician by ambulance if the delivery develops complications.

If the midwife had been the initial benefit applied for, there would most likely not be a problem even if the midwife had to refer the insured to a physician and hospital.

Right now, the baby is at risk. My advice is to focus more on a successful delivery of a healthy baby and far less on who delivers the baby and whether or not the insurance company is honoring its own policy's declaration of benefits.

As the insured has moved 400 miles from the physicians who wanted to do a C-section, that part of the poster's concern is moot.

File an appeal and wait on an answer. In the meantime, hurry to a reputable MD who is in the covered network and beg to admitted as a patient. It's way past time for the parents to lose their selfish temper tantrums; that's someone else's job now and that someone needs some serious help in getting here and surviving long enough to be a selfish, temper tantrum-throwing toddler.

[Due in a month]

ECM, yes, and still they're referring me to her for care.

Lya, the baby is not at risk. I am. The old doctors, OB/GYNs, were trying to push me into a c-section (their rate of c-sections is over 50% right now, far above the national average) because my small intestine is adhered to the front of my uterus. To even get to my uterus would require cutting through my small intestine, which the hospital's GI team strongly advised against. I was set to the GI team by the OB/GYNs for a surgical evaluation. The OB/GYNs decided they knew better after all, even though the GI team said that doing so would almost certainly kill me.

So the OB/GYNs and the GI surgical team they sent me to for an evaluation are on complete opppsite ends of the spectrum, with one side wanting the c-section anyway (while at this point acknowledging that it could kill me) while the other saying it would probably kill me. So which side would you suggest I take my advice from? The OB/GYN team did not give any reason to not allow a vaginal birth, just saying that they would only do a c-section as a "preventative" step, despite the known risk, to eliminate any risks from a vaginal birth.

A c-section as a "preventative" measure in my case is what causes the risks rather than lessening it.

So no c-section. PERIOD.

When we moved, I saw one OB/GYN here who again said he saw no reason to not allow a vaginal birth, but as the OB/GYNs who saw me longest advised it, it would carry too much medical malpractice risk to a new OB/GYN to allow anything other than following the advice of a previous OB/GYN team. So while he wouldn't be against a vaginal birth if I were his patient from a start, he would not allow a vaginal birth on grounds of prior team advising a c-section. He said there would be little luck in finding an area doctor to go against the old team's advice, and that, in my shoes, he's go with a midwife. He carefully worded it to prevent it being actual advice.

It is not a selfish tantrum to want the delivery that has the best chance of BOTH me and the baby living. Your suggestion is one that will require me to sign on a line to sacrifice my life when there is nothing to indicate that a vaginal delivery risks the baby or myself. How the hell is it selfish to want a chance to live and to fight against doctors trying to force me into a delivery method that GIs, specialists on intestines, are worried carry an almost-certain risk of death?

So.

Vaginal delivery is low-risk for both me and the baby. But OB/GYNs won't allow it because my intestine is adhered to the front of my uterus.

C-section means cutting through my intestine, which GIs are worried will kill me. Extremely high risk to me, how much risk to the baby is not know.

And I'm selfish and a tantrum-throwing toddler for wanting the first? I think you need a brain transplant if you think I'm a selfish baby for wanting the option that gives me just as much of a chance to stay alive as a baby. As it is, my life is on the line, so excuse me if I'm fighting to live at this point and see my next birthday.

[lya]

I stand firm in my assessment of the situation.

The insurance issue can be resolved later.

You should focus on calming down and delivering a healthy baby--at a hospital, under MD care, rather pursuing your own desire for delivery at home by a midwife who will have just met you.

Your self-induced hysteria has caused you to lose 4 pounds, cry frequently, and lose sleep. That is absolutely a most unhealthy approach to the last month of pregnancy/gestation and imminent delivery.

I have great respect for midwives, one of my closest friends has been a midwife for 30 years, has a Doctorate in Nursing, and would not 'touch' your pregnancy for numerous reasons. I believe your desired actions place you, the baby, and the midwife in less than favorable conditions.

Put your energies into finding competent medical care for the duration of your pregnancy and postpartum care. You can take on the insurance company when you have more time and better mental clarity. Any violation they may have committed will still be available for legal review after you deliver a healthy baby.