I have $3,343 in legitimate medical claims for 2011 that Blue Shield of California has paid nothing on or even credited in full towards my deductible. I have five claims from my dermatologist who is in network with Blue Shield of California and listed by them as a preferred provider. These claims are for medically necessary non-surgical treatment of TMJ and medically necessary treatment of the maxilla and mandible (jaw joints and jaw bones), which are covered in my health care plan on page 41. The claims are for $1650, $800, $250, $400 and $350. Blue Shield of California has not paid one dime on any of these claims. On each of these claims they have given me $5.58 credit toward my deductible for each claim regardless of the amount. My dermatologist had to submit these claims multiple times because Blue Shield of California representatives would repeatedly state that there was no record of the claim being received. I have verified dates of submission with my dermatologist. Blue Shield of California purposefully and willfully ignored these claims.
I also have a $543.00 claim from UCLA Oral Radiology. I have mailed and faxed this claim. Blue Shield of California denied ever receiving the claim even though I have fax confirmation that it was sent. It was not until my recent complaint with the California Department of Insurance that they acknowledged this claim for the first time, more than four months after it was initially submitted.
The response from the Blue Shield of California representative in regards to my complaint with the California Department of Insurance was laughable. She did not even list the correct name of my dermatologist, instead listing another doctor I've never been treated by. She continued Blue Shield of California's policy of willful and intentional evasion by not addressing half the complaint and claiming that what had been processed was correct.
Let me ask this question of Blue Shield of California, when a patient has $3,343 in legitimate medical bills from doctors who are preferred providers and in network and Blue Shield of California doesn't pay a dime, what is the point of me paying for health insurance? Furthermore, how does a patient ever reach his or her deductible when regardless of the amount of the claim, he or she is only credited $5.58 for each claim toward the deductible?!
Blue Shield of California willfully and intentionally evades their legal obligations by purposely stating that claims have not been received when they've been sent multiple times, by not paying claims for legitimate medical services from in-network providers and by purposely not crediting those claims toward the patient's deductible.
The grievance process is a joke. I submitted a grievance first to Blue Shield of California before filing a complaint with the California Department of Insurance. Blue Shield of California guarantees they will respond within thirty calendar days. I never received any response from Blue Shield of California.
Blue Shield of California's PR department is also very busy touting that they are a non-profit and they've committed to only taking two percent profit and any profit over that will be sent back to the customers. I've received two of these refunds on my monthly health premium recently. One refund was for about thirty dollars and the other one was for forty dollars. What a great racket Blue Shield of California has going! Refund customers seventy dollars but deny $3,343 in legitimate medical claims! And of course Blue Shield of California increased my health insurance premium for 2012 even though they have not paid one dime on any of these claims.
I am currently in the midst of a complaint with the California Department of Insurance over these claims. I will continue to update this post. I encourage anyone who is dealing with the unethical and illegal behavior of Blue Shield of California to file a complaint with your state's department of insurance.
