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Insurance Doesn't Ensure Care

	May 31, 2005

HEALTH

Having Insurance Doesn't Guarantee Coverage May 31, 2005; Page A8 Buying individual insurance doesn't mean that coverage of medical treatments is guaranteed. Much depends on state rules and a policy's fine print. When Jean Green, a 36-year-old Braille translator from Cave Creek, Ariz., had a baby girl named Alex last May, she knew she had to move quickly to get the infant insurance. Mrs. Green's group plan at work covered the baby for just 31 days, and she couldn't afford to add her to her policy. So she applied at the same company where her two older children had policies. The application was rejected because Alex had a closed tear duct, a fairly common condition among newborns. Mrs. Green tried again, with Blue Cross and Blue Shield of Arizona, the company that provides her group plan at work. It took time to get Alex's medical records to the company. When Blue Cross issued coverage on July 15 last year, Alex had been uninsured for about two weeks. At Alex's two-month check-up in late July, her pediatrician said that her misshapen skull, attributed at first to normal birth trauma, hadn't gone away. In September, a specialist diagnosed Alex with a rare birth defect that was causing her skull to grow abnormally. Blue Cross denied coverage for the specialist's visit, saying that the bone disorder was a "pre-existing condition" -- a health problem that predated Alex's insurance policy. Blue Cross officials pointed to physician notes from late May mentioning that Alex had facial "asymmetry" and a "wide" fontanelle, the soft spot in babies where the skull bones haven't fused. Mrs. Green filed an appeal with the company, but officials denied it. Meantime, doctors said Alex needed a $90,000 operation to relieve pressure to avoid damage to her brain and eyes. Alex's eyes and ears were lopsided, and doctors wanted to correct the problems before they got worse. Mrs. Green scheduled the surgery, even though Blue Cross was signaling that it wouldn't pay. The policy excluded coverage of a pre-existing condition for 11 months -- far too long for Alex to wait. Mrs. Green next turned to the state's insurance department. But the department ruled that Blue Cross had properly followed its own rules. If not for the gap in Alex's coverage, Blue Cross officials say they wouldn't have viewed her birth defect as pre-existing. She would have moved seamlessly from one Blue Cross policy, in the group market, to another, in the individual market. If Mrs. Green had kept Alex on her own policy for another month, for example, there wouldn't have been a problem. "The failure to get that done was really personal responsibility," says Dick Hannon, senior vice president of marketing and provider affairs at Blue Cross and Blue Shield of Arizona. Mr. Hannon says Blue Cross worked to help Mrs. Green but couldn't make an exception to its rules because it would have had to do the same for others. Mrs. Green says she wasn't aware that a gap in coverage would have such a devastating effect -- and pointed out that the insurer didn't raise any objections when initially reviewing Alex's medical records. "They had all this information from the hospital and doctors," Mrs. Green says. "They never said anything." Alex would have had more protections in an employer-sponsored plan or in individual plans in many other states, where there are stronger consumer protections. But in Arizona "it's the most wide-open it can be," says Karen Pollitz, project director at Georgetown University's Institute for Health Care Research and Policy. Eventually, Catholic Healthcare West, the parent company of the Phoenix-based hospital where the surgery was scheduled, helped get Alex into a state program for children with costly health problems. The surgery went ahead in December, with the state picking up most of the tab. Now a year old, Alex's scars have healed and she seems to be growing normally, Mrs. Green says. ---- Sarah Lueck URL for this article: http://online.wsj.com/article/0,,SB111750175890146701,00.html   Hyperlinks in this Article: (1) http://online.wsj.com/article/0,,SB111749120504446489,00.html (2) http://online.wsj.com/article/0,,SB111750212414346709,00.html (3) http://online.wsj.com/article/0,,SB111749136000246491,00.html

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