A recent claim denial by Blue Cross has left a California couple stunned – and angry. After telling the couple that full time nursing care for their severely disabled son was ‘medically necessary’, Blue Cross simply changed its mind, without a valid reason, forcing the couple to rely on Medi-Cal and file a lawsuit. The couple’s attorney calls the insurer’s claim denial, ‘bad faith at its worst’.

A rare disorder

A California couple’s 13-year old son developed a rare health disorder shortly after birth and now requires a full time nurse to assist his parents with round-the-clock care. According to a recent article in the Los Angeles Times, the bedridden teen cannot sit up, speak or eat solid foods and is subject to violent seizures. Blue Cross, their insurance company, paid for that nursing care for several years after telling the couple that a nurse was ‘medically necessary’. The couple paid their insurance premiums – nearly $12,000 per year – on time and continued to care for their son with the needed assistance of a full time nurse.

Outrageous conduct

One day, the couple received a letter from Blue Cross denying further nursing care because the couple had ‘exceeded their policy limits’. Knowing this wasn’t true, they contacted Blue Cross to straighten things out. The insurer agreed that they hadn’t exceeded their policy limits, but quickly sent a second letter denying coverage for a different reason.

In the second letter, Blue Cross explained that a gynecologist (yes, really) reviewed their son’s case and decided that nursing care was no longer medically necessary. Bewildered by Blue Cross’s outrageous conduct, they had their son’s doctors send Blue Cross proof that this wasn’t true – but the insurer still denied their claim.

Forced to rely on Medi-Cal and file a lawsuit

The couple, who aren’t on an employer-based health plan, had no choice but to rely on Medi-Cal to continue having a nurse assist them with caring for their son. In the meantime, they hired an attorney to represent them and are now in arbitration with Blue Cross pursuant to their policy’s requirements. In the Times article, their attorney implied that Blue Cross’s actions were highly inappropriate. He was quoted as saying, "For eight and a half years to put in writing that treatment is medically necessary, and then out of the blue to say it is not, is bad faith at its worst.”

If you or a loved one has been wrongfully denied valid insurance benefits, contact a qualified attorney who understands bad faith insurance practices. To contact an attorney for a free, no obligation consultation, please click here.