Below is a letter that I’ll be mailing tomorrow to Speaker of the House Nancy Pelosi.  Ms. Pelosi has five grown children and twelve grandchildren.  I’m hopeful that my letter will reach a member of her staff and eventually find it’s way to Ms. Pelosi herself.  With health care as such a current “hot button” issue, now seems like an opportune time for me to get my story out there.

Office of the Speaker
H-232
US Capitol
Washington, DC 20515

January 13, 2010

Dear Madame Speaker,

I am writing to you and enclosing my recent medical appeals because I wanted to bring to your attention the extensive and devastating effect that our current healthcare and insurance system is having on my family.  My daughter, Lily was born on August 10, 2009 via a medically necessary cesarean section because she was failing to descend and exhibiting non-reassuring fetal heart tones.  Blue Cross Blue Shield of Arizona (BCBSAZ) has denied the medical claims resulting from my cesarean section because my policy did not include maternity and only covered a cesarean section if they deemed it to be medically necessary.  BCBSAZ has maintained that my cesarean section does not fall within their definition of “medically necessary” and under their defined “complications of pregnancy”.  Therefore BCBSAZ will not cover the insurance portion of the claims associated with the delivery. BCBSAZ has also denied claims for visits to my hospital’s OB Triage unit that occurred pre-term (before 37 weeks gestation) because based on the BCBSAZ definitions, pre-term labor is not considered to be a complication of pregnancy.

I requested a Level 3 External Review asking BCBSAZ to overturn the previous denials, which in total are approximately $31,000.  My husband and I did everything right on our end, paying out-of-pocket $8,000 for my pre-natal care and a self-pay labor and delivery package with my hospital.  It was my intention to have a vaginal delivery.  My husband and I did agree that during the delivery we would rely on our doctor’s direction and medical expertise and if our doctor were to recommend a c-section out of medical necessity for Lily or me, that we would follow the doctor’s recommendation.

I believe that BCBSAZ has acted in bad faith and is attempting to make medical decisions for me that should instead be made by my health care providers.  I wanted you to be aware of my appeal because I sincerely hope that no other health insurance customers will have to go through what we have.  I have spent countless hours to appeal my denied claims and a significant amount of money printing and mailing documentation regarding my appeals.  It has become like a second job.  Both my husband and I are self-employed and my husband is a full-time education major at Arizona State University. I went back to working just four short weeks after the birth of my daughter so that I could help to contribute financially to my family.  My husband went back to work immediately following her birth and began a new school term the week following Lily’s birth.   My business and our livelihood is now suffering because of the hours that I am spending in the appeals process.  More importantly, as a new mother, I am losing precious time with my daughter that I will never get back.

Financially this is a potentially devastating event for our family.  My husband and I are both very hard working, contributing members of our community and country.  After doing everything right, we are now left with tens of thousands of dollars in medical bills that we simply cannot afford and never anticipated.  It is also possible that due to these bills we won’t be able to have more children, because we cannot afford it.  We have been married six years and waited to start a family until we were financially stable and able to provide our family with a secure and comfortable life.  This is perhaps the most devastating part of all.  Because an insurance company is more concerned with making money and creating such limited parameters on what they consider to be medically necessary, my life, my husband’s life and my daughter’s life are forever changed.

When we bought our policy in May of 2008 it was our understanding that if I had to have an emergency cesarean section it would be covered.  On October 1, 2008 BCBSAZ changed our policy to no longer cover cesarean sections that are performed due to fetal distress.  If my baby is in distress and my doctor recommends performing a cesarean section, what could be more medically necessary than that?  In addition, how does a condition go from being medically necessary one day to no longer being medically necessary or a defined complication of pregnancy the next day?  It would seem to me that the change in definition is driven by one thing and one thing only, money.

I also find it abhorrent that an insurance company is allowed to change my policy after I have purchased it.  With what other major purchase does this occur?  My mortgage doesn’t change because my bank needs more money.  My car payment doesn’t change because the manufacturer doesn’t sell that model any more.  Why then can an insurance company change my policy after I’ve agreed to their terms the first time?  Again, the answer seems to point to the financial bottom line.

I received notice from the Arizona Department of Insurance on January 13, 2010 that our Level 3 External Review had found in favor of BCBSAZ because my claims did not fall within the BCBSAZ definition of “complications of pregnancy”.  We are now in the process of requesting a hearing with the Office of Administrative Services.

Madame Speaker, I am asking that you do whatever you can to help ensure that no other parent is told that protecting their child’s health, their child’s safety and that following their doctor’s expert advice is not medically necessary.  I’m asking you to stand up against insurance companies that are more concerned with making exorbitant profits than with their customer’s medical health.  I’m asking you to help ensure that other families like mine are not devastated and financially ruined because of an insurance company’s refusal to pay.  As a mother and grandmother I’m asking you to consider how you would feel if your child’s or your grandchild’s health, life even, was on the line and an insurance company told you it didn’t matter.

Sincerely,

Lily’s mom, Elizabeth Langford