Anthem refusing to pay

[goaded]

What is the name of your state? IN



Despite being told that my son would be covered the minute he was born; Anthem is refusing to pay for my sons neonatal care. They are stating that is was pregnancy/birth charge and I didn't have that coverage. The care was not part of birth, and it was not part of the pregnancy!

I pay this morons a butt load of money each month, and they are ALWAYS trying to get out of paying for stuff! They aren't an insurance provider, but a profit making machine!

 

[cbg]

Thank you for sharing your story. When you have a legal question, be sure to let us know.

You might want to include at that time whether this is individual insurance or a group policy through your employer.

 

[ecmst12]

Frequently, the neonatal care IS considered part of the pregnancy/birth charge. This is to get the hospital paid quickly without having to wait for the NB to be issued his/her own policy number. We would need more information about your policy to tell you anything more.

 

[goaded]

My policy states that new births are covered from the moment they are born until 31 days. I added him to my policy 3 days after he was born and paid / paying the additional premium.

Newborn and Adopted Child Coverage

Any Dependent child born while the Subscriber or Member's spouse is eligible for coverage will be covered from birth for a period of 31 days.

...

To continue coverage beyond the 31 day period after the child_s birth or adoption you must notify Us by submitting an application to add the child under the Subscriber_s Contract and provide any applicable premium.

I have found nothing in my policy that states neonatal is part of pregnancy/birth. IMO it is clearly not part of either of those stages. If it is written somewhere that it is part of those stages, its in a paper(s) I was never supplied and as such is not part of my contract!

In the back of my policy it states "Exclusions: #45 - For Maternity Services, except We will cover Complications of Pregnancy as stated."

In my policies definitions "Maternity Services" is not covered, so I went online at Anthem it is defined as .... "Care required for pregnancy and delivery." well - neonatel is not part of those stages!

Heck better off for me to not even have insurance if they arent going to pay up when I make a claim! Anthem has paid out about 15-20% of what I have paid them the last 2 years - thats one heck of a profit for refusing claims.

 

[cbg]

You didn't answer my question. And I had a reason for asking it.

 

[goaded]

This is an individual health plan, I pay dearly; 100% of the premium out of my pocket.

 

[cbg]

Can't help you then, sorry. My experience with health insurance, while considerable, is 100% with group employer plans, and the laws and regs can differ.

 

[moburkes]

You've provided the answer to your own question (unfortunately).

My policy states that new births are covered from the moment they are born until 31 days.

They are only covered if you have paid for a "rider" for maternity services. If maternity coverage was not added (most companies don't even offer this, since people would only purchase the insurance because they are about to be pregnant or are newly pregnant), then there is no automatic coverage for the newborn.

I added him to my policy 3 days after he was born and paid / paying the additional premium.

Since you added him to the policy, he is now covered from that day.

Heck better off for me to not even have insurance if they arent going to pay up when I make a claim! Anthem has paid out about 15-20% of what I have paid them the last 2 years - thats one heck of a profit for refusing claims.

There is no CLAIM if there is no COVERAGE.

I have found nothing in my policy that states neonatal is part of pregnancy/birth.

That's because you were given incorrect information by that poster.

Here's your answer:

"Exclusions: #45 - For Maternity Services, except We will cover Complications of Pregnancy as stated."

Again, unless you purchased a rider for maternity coverage, then the birth isn't covered either. Unfortunately you must have spoken to someone in customer service who wasn't paying attention to the information that they gave you. The problem, though, is that the consumer is responsible for knowing what is and isn't covered. Since your policy clearly states an exclusion, that would have been the time to contact customer service for clarification of what that exclusion means.

 

[goaded]

No, sorry you are wrong, my policy clearly states newborns are covered from the moment they are born. I dont need a maternity waver for that to happen. Once the child is born - the second they take a breath maternity is over and they are a dependent. Thats in the policy and Anthem told me this when I called them to add him that point is not contested by me nor Anthem.

Anthems position is that since the baby went home at the same time mom did, that the complications (neonatel care) were not severe enough to warrent coverage. They pointed out a clause in my policy that refers to an exclusion for "routine nursery care of healthy newborns" - Anthem states that is not a covered claim.

It's my position that since my son decided to come out 1 1/2 months early, it was not exactly routine. Further "after" birth he was having difficulties breathing, so it could be argued that he wasn't 100% healthy. They say if it was routine we wont pay, if it wasnt we will - therefore IMO they should be paying in this instance.

You are correct, birth wasnt covered - I had to pay the hospital and the doctors 100% of those fees. My son was covered the second he was born; and any expenses he received should be covered. (Accept routine nursery care for healthy newborns) LOL Why that would be excluded I dont know, but I do know it wasnt routine and he wasnt healthy. Thank god he is doing great now!

I have filed a grievance - appeal and hope that they change their minds.

 

[ecmst12]

You filed an appeal, that's about all you can do and hope for the best. If he didn't actually receive care over and above what would be considered routine well baby nursery care, and wasn't given any diagnosis other then those for a healthy newborn, your chances of getting the care paid for are pretty low. Did he need treatment for the breathing difficulty or did it resolve on its own?