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ObamaCare Clustefuck: Be sure to record any conversations you have with your insurance company


In their complaint filed in California state court on Wednesday, San Francisco residents John Harrington and Alex Talon accused Blue Shield of misrepresenting that their plans, sold on California's health exchange, would cover the full provider network advertised on the company's website.

They sued on behalf of a class of people who had purchased so-called "preferred provider organization" plans from the insurer only to realize that the doctor and hospital networks for their plans were limited.

Harrington bought a so-called silver plan on California's online exchange while Talon bought a platinum plan through the insurer's website. They said they made their choices based on Blue Shield's alleged representations that their doctors would be covered.

After receiving medical treatment numerous times between January and March, Harrington and Talon later discovered that their providers were not covered, forcing them to pay the charges out-of-pocket, the complaint said.

So, it's not just the narrow networks, it's that the insurers conceal how narrow the networks really are.


David Cienfuegos said his wife was told by Anthem Blue Cross that his doctor was part of the insurer's coverage network, but then was left with the tab for about $5,800 in medical costs after Anthem insisted that it never said any such thing.

In this case, though, Cienfuegos, 40, has a digital recording of the Anthem rep clearly saying his surgery would be covered.

And he's suing to hold the insurer accountable.

In its Feb. 19 letter rejecting Cienfuegos' appeal, Anthem said the company's own records show that "no specific provider was mentioned in the conversation nor was it noted you were misinformed about participating status for this specific provider in question."

That's just b-i-z-a-r-r-e.

Cienfuegos' wife can be heard on the recording spelling out the provider's name, and the Anthem rep can be heard confirming both his in-network status and that the procedure would be covered.

And then they try to deny coverage anyhow!

NOTE Hat tip, Hipparchia.

No votes yet


Alexa's picture
Submitted by Alexa on

should be checked both at the time that an appointment is made AND very late the afternoon before--or better yet, the morning of an appointment.

Precisely for this reason, we never set very early morning medical or lab non-emergency appointments.

And, there usually is no "guarantee"--if the insurer's representatives are open and forthright--that a provider is "in-network" beyond the day that an inquiry is made.

Also, get pre-d's when possible. Often done with dental and vision insurance.

Rainbow Girl's picture
Submitted by Rainbow Girl on

"So, it's not just the narrow networks, it's that the insurers conceal how narrow the networks really are."

Worse. The insurance companies are affirmatively lying to the policy holders that a doctor is in the network. Perhaps a mere nuance but in my view, a quite significant one. Legally too, the case for fraud is always "easier" when the defendant made an affirmative misrepresentation (aka lied) to the mark customer.

I'm cheering both lawsuits from the sidelines - in a big way. It is very heartening to see that the first lawsuit has been brought as a class action. Since this is no doubt happening in every state, this should get interesting. (*)

Note - CFPB (supposedly the big new consumer fraud-cop on the block - bwa ha ha) nowhere to be seen or heard from. Nor DOJ civil division. Nor California State Attorney General.

(*) My penny ante bet with myself - first thing the Insurance Company defendants in these cases do is ask the courts to put everything under seal because trade secrets (see also, Yves Smith's excellent ongoing reportage on asset stripping shops private equity firms hiding their skimming frauds on pensioners nation-wide by invoking "trade secrets" and "competition" as to their contracts with the marks pension managers.

Submitted by lambert on

And "affirmatively lying" is better framing.

Presumably, this is the first trickle of stories, because it takes some months for people to get insured, seek treatment, and then get the bills, and then find out they're not covered. Like 60 days, maybe?

Submitted by Dromaius on

The lying is a genius way of avoiding paying. Encourage "customers" to go to out of network doctors for major procedures by saying, oh yes, they're in network. When the bill comes due, say, oh sorry they were out of network. No redo button on medical procedures, unfortunately.

Always get everything the insurance company says either on recording or in writing....or both.

Isn't it just wonderful that the good Democrats saddled us to these crooks?

Alexa's picture
Submitted by Alexa on

providers "contract," and different providers' contract periods (usually one year) begin and end at different intervals.

(BTW, I, too, am on the side of anyone who is defrauded.)

But I feel compelled to point out--for one's own protection--it is incumbent upon each insurance beneficiary to verify the provider's current participation in-network at the time of each appointment/procedure/surgery.

Which isn't to argue that these people weren't wronged. It will all depend upon what the "current" provider in-network status was when they obtained the service. Again, calling and being told that a provider is in-network "once," doesn't ensure that a patient's future office visits/tests/procedures/surgeries will be covered.

Unfair or not--that's just the way it is in many self- and fully-funded insurance plans.

Rainbow Girl's picture
Submitted by Rainbow Girl on

Alexa -- "these people" went through all the due diligence that any human being should ever be required to do and then some to make sure their doctors were in-network. And they were affirmatively lied to. So no amount of due diligence would have cured this.

Your post does, however, highlight one of the totally unacceptable features of all "health" insurance policies that aren't straight fee for service (no-network policies - don't know if these even exist anymore). This constantly moving target of doctors falling out of networks in mid-policy year makes it *impossible* for the hapless and ripped off policy holder to be sure that a doctor is in-network. The day before you go for surgery, Doctor Jones is in-network. But "oops" - on the day-of it just so happens his contract with your carrier expired at midnight. Oh well. Not in network anymore - you pay $100K as a surprise punishment for being ill, paying god damn premiums and deductibles and doing more due diligence than anyone should ever have to do when they're paying for something upfront.

I mean, in what other context does a fundamental material term of a contract have the ability to just change unilaterally? This is one reason that "health" insurance is structurally a fraudulent product.

Rainbow Girl's picture
Submitted by Rainbow Girl on

Shorter: if a physician who is listed as "in network" when the prospective policyholder is researching the network *in order to decide whether to buy the policy* (so that he/she can intelligently decide to pay premiums and deductibles and everything else in order to continue receiving medical care from his/her current/desired doctor(s)) is liable to simply drop out of the network some time *after* the policyholder buys the policy, then the only honest thing to do is for all of the mouthpieces for the New Obama Insurance Scheme to tell potential policyholders that they simply shouldn't use the "in network" list they are given while trying to shop intelligently. Because it's an ephemera; by definition.

How should Obama do this? Take out massive time on prime-time network and cable channels and run ads in 50 point type clarifying to potential "health" insurance purchasers that they should NEVER, EVER purchase a policy thinking that their doctor's services are covered.

And we get rid of the fraudulent and pretend spiel about "informed consumers" and "oh, very important to spend 48 hours trying to dig out what a particular policy's doctor network is or isn't."

Alexa's picture
Submitted by Alexa on

an acknowledgement that the "specific people" featured in this piece may have done their "due diligence." I certainly hope that they will be compensated for their loss.

Having been steeped in "insurance" for decades (due to a family business), I'm sorta naturally aware of the stance of the typical insurance company.

(Which by no means indicates that I'm in agreement with it!)

Mr A and I actually take the precautions that I mentioned above. And, yes, these measures do sound absurd.

But we've received tens and tens of thousands of dollars of health care within the past couple of years, and by following this dumb procedure, we have yet to be charged out-of-network expenses--"accidentally."

Not to say that this will never happen. We just work hard to avoid it.

I only meant to be helpful.

Submitted by lambert on

I think that some might point more emphasis on the treading, and others on the minefield and its minefield nature, but I think all agree on the general principle.

What really ticks me off is the forcing part. And there keep being more mines!

Alexa's picture
Submitted by Alexa on

how many ways do I have to say that "I" don't endorse deceptive behavior on the part of insurance companies? Or for that matter, the health insurance provider network system.

And, when on earth have I argued "because markets" for the sake of supporting our broken private health insurance/care system? I haven't, period.

As far as I can tell, I'm as enthusiastic a proponent of (not to mention user of) our nation's most progressive and "centralized" health care systems, as anyone here. And have always expressed such.

I was simply pointing out that there is one precaution that one might want to take to (hopefully) mitigate against incurring "out-of-network" expenses. It isn't foolproof, but I thought it was worth mentioning.

For all I know, there may be a handful of readers who are newly insured with little experience dealing with insurance companies, who could benefit from knowing that network provider information does not necessarily extend for the life of one's health insurance policy (term).

And one thing I do know is that insurers "write the rules." (in a private health care system)

So the only way to absolutely get around the possibility of "network provider problems" is to not participate in the private insurance system. (Which Mr A and I will thankfully no longer have to do after this year.)

Hope this clarifies my observations. They were in no way intended to "dispute any of the contentions regarding the Harrington or Talon situations" as stated in this post. Nor were they intended to defend private health insurance carriers or their behavior(s).

Whew--must be something in the water, LOL!