I've never had a major, non-emergency, hospital experience. Perhaps I am just naive. But I was suprised last week when BlueCross of Utah sent me letters last week denying my claim for the hip surgery. I don't have much information yet. BlueCross has a policy of managing their front phones with people who don't know as much about insurance as you or I. But what they seem to be saying, rather obtusely -- the letters they sent me said I wasn't insured at the time, a statement they now retract-- is that I did not qualify as a candidate for the hip resurfacing procedure, which makes it an "investigational" procedure and they don't pay for investigational procedures.
BlueCross has paid the providers but they will now get that money back, presumably by deducting from other monies owed them. If worse comes to worst I will be on the hook for $35,000. I had called BlueCross several times before the surgery to be sure I was covered. I spoke of that somewhat disquieting experience previously (again the incompetence of the people that man their phones). I was eventually told that they did cover the procedure and that I was insured. The caveat now appears that I was covered if they determine I qualified for it. The surgeon's office also called the insurance company to verify I was covered. What I didn't see coming was that BlueCross does not necessarily accept the surgeon's decision to use this HR procedure, and that they don't decide until after the fact. If that is standard industry procedure I will go ahead and let myself have an angry discussion with the surgeon for not warning me.
More as I learn something.
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