Home » Featured, Health & Fitness

Homebirth and Insurance Pitfalls

12 April 2011 5 Comments

We counted ourselves pretty lucky.  When Tara was pregnant with Theory, we contacted our insurance company, United Healthcare, and asked that our midwife be considered as “in-network”.  They were happy to provide us with what is called a gap-exception letter.

A gap-exception letter is issued when there are not enough medical professionals or services within the network to serve you.  They allow you to reach outside the network to get care, and bill you as if they were in-network.  In our case, there were not enough home birth midwives in the city and so we were allowed to have River and Mountain Midwives of New York be our provider.

Our midwife attended the birth and provided immediate care to Tara and Theory.  She later came back to the house to check up on both Tara and Theory.

Soon thereafter, the bills began to arrive.  Tara and Theory were billed as “in network.”  We were really satisfied.  We had the birth that we had planned, the insurance company probably saved a lot of money, and we had a provider that we felt very comfortable with who in turn was paid for their services.

So I was not expecting a lot of a headache with the birth of Win.  After all, same insurance company, same exact request.  Our midwife was different as we had moved to CA. But otherwise, nothing had really changed other than I had switched employers.  My new employer was self-insured but used United Healthcare to administer the policy so the infrastructure was the same.

When Tara was pregnant with Win, I contacted United Healthcare and again asked for a gap-exception letter – which was granted.

So after the birth of Win, imagine my surprise when we started to get bills for Win, stating our mid-wife was out-of-network for Win while in-network for Tara.

The insurance representative stated that we would have had to have gotten a gap-exception letter for Win prior to the birth in order for Win to be covered as in-network.  Now get this — there is no way to have an unborn child covered prior to birth as there is technically no person yet.  Logically then , there is NO WAY to get a gap-exception letter to cover the portion of the cost of the birth that is associated with the newborn as patient during a birth.

Apparently, this is a frequently used tactic by the insurance companies to not pay out claims.  It really should not be such a surprise.  Health insurance companies have been known to chronically do this with providers.  In 2005 WellPoint paid and invested  $450 million after the State of California accused them of consistently underpaying providers.

After half a dozen calls with the insurance company, I had enough.  I filed a suit against them in small claims court in Marin County Court.

Filing a claim against a national insurance company is pretty easy, but you need to know what to do.  The small claim forms are typically available online and you can file by mail.  You have to be careful that you name the company correctly – which is tricky.  United Healthcare, Inc., goes by many names and owns many subsidiary companies so you need to know which entity the complaint is against.

You also need to know who to serve with the legal documents.  Companies that operate across state lines must have a legal representative in every state where they do business.  These are servicing companies that typically are located in some generic office park.  For United Healthcare, Inc., for example, the servicing agent is a company  C T CORPORATION SYSTEM and they are located in Los Angeles.   What does the generic name stand for?  Who knows.  If you go to their website, you read “CT Corporation is committed to helping corporate legal departments and law firms find cost-effective ways to embrace compliance best practices, reducing operational and brand risk.”  In other words, they help you comply to your legal requirements in the most cost-efficient, oblique way so as to make it hard for people to trace your companies activities back to the brand.  Nice.

In any case, you can  typically locate this company through the Secretary of State’s online business search.  Not every state has online searchable databases, unfortunately.

Once the documents are filed, you receive papers with a court date.  When I saw the Nave v. United Healthcare Services, Inc. on the forms, I felt empowered.  I still may not win, but I am going to have my day in court to express how misleading and disingenuous I feel the practices are and unrepresentative of the spirit of the agreement.

Postscript:

Two weeks later, I received a call from an in-house attorney from United stating that she sees where they made an error and is trying to address the issue internally.  The following day I received an email confirming that a  claim rep was investigating the matter.  Soon thereafter I received a settlement agreement in the mail, which as is typical included a confidentiality clause so I cannot divulge any of the fine details.

So the day before I was set to go to court I deposited the check, drove down the street to the courthouse and filed the paper to let them know the issue was settled.

In the end, we were reimbursed completely for our birth.  I encourage other folks to pursue their rights through the small claim court system.  It is easy, cheap, and designed specifically to give everyday folks a right to an impartial third party.

5 Comments »

  • Jeff Shattuck said:

    Congrats. Winning against a big insurance company is not easy.

    For what it’s worth, I’ve had good luck with United, despite their oftentimes exasperatingly complex procedures.

  • Ozzie said:

    I am SO going to do that! Thanks Ari!!

  • angie said:

    Thanks for sharing. We now have United Healthcare in CA and I’m not finding any in-network midwives.
    This has been very helpful.

  • Kelly said:

    Thank you for sharing this. I am about to request the gap-exception from UHC to get in-network for the midwives I want, so it’s good to have some inkling of what is to come!

  • Anne said:

    Thanks for sharing your story. I have UHC and live in Missouri. I hope to have as much success as you’ve had!

Leave your response!

Add your comment below, or trackback from your own site. You can also subscribe to these comments via RSS.

Be nice. Keep it clean. Stay on topic. No spam.

You can use these tags:
<a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <s> <strike> <strong>

This is a Gravatar-enabled weblog. To get your own globally-recognized-avatar, please register at Gravatar.