Assurant Health - Maternity Benefit - "Normal" Vaginal Delivery

[TxOnline]

Just got a call from a client about Assurant's Maternity Benefit (in Texas).

It seems that they processed her maternity claim (hospitalization) against Major Medical (not Maternity) because she had a small tear during delivery (with a stitch or 2)....and Assurant processed it as a "complication".

I thought that a small tear during delivery WAS "normal".
I thought that stitches after a delivery WAS "normal".

If Assurant's Maternity Benefit applies for a "Normal Vaginal Delivery", and a "tear" disqualifies the benefit, they won't pay-out many maternity claims, will they?
(Deceptive!)

The hospital will not re-code the claim. They HAVE accurately coded the claim as 664.11
Assurant is saying that this is NOT a "maternity" code.

Has anyone else experienced this problem with Assurant?
Did Assurant JUST start doing this???

Should we complain to the Tx Dept of Insurance?

Any ideas/suggestions?
Thanks!

 

[somarco]

Re: Assurant Health - Maternity Benefit - "Normal" Vaginal Delive

664.11 - During delivery; second-degree perineal laceration; delivered, w/ or w/o antepartum condition

Hard to say based on this limited description but unless Time has a very liberal definition of complications, it would seem this is a normal delivery.

How does the policy define complications? Can you get a list of CPT-4 codes that correspond with their definition of complications?

 

[TxOnline]

Re: Assurant Health - Maternity Benefit - "Normal" Vaginal Delive

An insurance company can call almost anything (even minor) a "complication" if they want.

They make their own "rules" in the Claims Dept's....and don't give us access to them (unless we call....for EACH situation...AFTER the milk is already spilled all over the table in most cases).

Assurant did NOT call it a "complication-of-pregnancy". They simply called it a "complication", which falls under "Medical" benefits.

I've NEVER been successful in getting a list of CPT codes from ANY insurance company, but I GUESS it's worth asking.

I was just HOPING that another agent (or 2) had crossed this bridge (before me)...and could tell me how to get to the other side.

And, ALSO wanting to "alert" the troops that this headache NOW exists (with Assurant Health Maternity Option)....so that we are ALL forewarned (and possibly prepared to address the issue).

I'll post the Assurant Health Policy wording in a minute....but it's somewhat "vague" (as usual) even though Assurant's policies ARE more-detailed than MOST of the others.
- - - - - - - - - - - - - - - - - -

"Page​

​

​

​

54 Medical Coverage​

Complications of Pregnancy​

The following specific conditions arising from a pregnancy that begins after the Effective Date of
coverage for a Sickness associated with pregnancy for a Covered Person.
1. Termination of ectopic pregnancy.
2. Spontaneous termination of pregnancy (miscarriage) occurring during a period of gestation
in which a viable birth is not possible.
3. Nonelective
caesarean section delivery.
4. Conditions requiring hospital confinement (when pregnancy is not ended), whose diagnosis
are distinct from pregnancy but are adversely affected by pregnancy or are caused by
pregnancy such as acute nephritis, nephrosis, cardiac decompensation, missed abortion and
similar medical and surgical conditions of comparable severity.Spontaneous premature
delivery of a nonviable fetus."


***

"MED: 085.001.TX​

Maternity Care Services​

This coverage is optional. The Benefit Summary will indicate if the optional maternity care
services coverage is included in this plan.
1. Prenatal care.
2. Delivery for a minimum of 48 hours of Inpatient care following an uncomplicated vaginal
delivery and a minimum of 96 hours of Inpatient care following an uncomplicated caesarean
section delivery.
3. Postpartum care.
4. Routine well newborn care, including nursery charges, from the moment of birth until the
mother is discharged from the Acute Medical Facility.
Covered Charges will be considered for the Covered Person after the Benefit Waiting Period
shown in the Benefit Summary provided that a Health Care Practitioner determines the
pregnancy began after the Benefit Waiting Period and the pregnancy terminates while this
coverage is in force.
Benefits will only be considered for Covered Charges Incurred while the maternity care services
coverage is in effect. Please refer to the Extension of Maternity Benefits provision for additional
information.
Charges that are covered under the Complications of Pregnancy provision above are not covered​

under the maternity care services coverage."

 

[somarco]

Re: Assurant Health - Maternity Benefit - "Normal" Vaginal Delive

An insurance company can call almost anything (even minor) a "complication" if they want.

They make their own "rules" in the Claims Dept's

That's news to me. I assume you have first hand experience to back up that allegation.

I've NEVER been successful in getting a list of CPT codes from ANY insurance company, but I GUESS it's worth asking.

Perhaps you didn't ask the right question, or the right person. I have never had that problem.

this headache NOW exists (with Assurant Health Maternity Option)

Sorry, while I am no fan of Time, one case does not a conspiracy make.

 

[IndividualHealthGuy]

Re: Assurant Health - Maternity Benefit - "Normal" Vaginal Delive

How much does this matter, now that they don't even offer the maternity option?

 

[HealthGuy]

Re: Assurant Health - Maternity Benefit - "Normal" Vaginal Delive

Oh man, it matters....Assurant is evil - they won't cover a vaginal tear as maternity....evil man, pure evil. Obamacare will correct these injustices.

 

[txnewbie]

Re: Assurant Health - Maternity Benefit - "Normal" Vaginal Delive

Just got a call from a client about Assurant's Maternity Benefit (in Texas).

It seems that they processed her maternity claim (hospitalization) against Major Medical (not Maternity) because she had a small tear during delivery (with a stitch or 2)....and Assurant processed it as a "complication".

I thought that a small tear during delivery WAS "normal".
I thought that stitches after a delivery WAS "normal".

If Assurant's Maternity Benefit applies for a "Normal Vaginal Delivery", and a "tear" disqualifies the benefit, they won't pay-out many maternity claims, will they?
(Deceptive!)

The hospital will not re-code the claim. They HAVE accurately coded the claim as 664.11
Assurant is saying that this is NOT a "maternity" code.

Has anyone else experienced this problem with Assurant?
Did Assurant JUST start doing this???

Should we complain to the Tx Dept of Insurance?

Any ideas/suggestions?
Thanks!

They probably processed it as a "complication" because the alternative would have been for the doctor to perform an episiotomy to elarge the vagina opening, thereby assisting the birth-AND THAT is a WHOLE other charge that possibly would have been debated! Hate to say it-but, from a male-dominated industry stand point (in terms of underwriting) I think a "tearing/ripping" of the vagina is deemed more acceptable as a "complication" then performing an extra (preventive) procedure....It's a shame...like being told you have to have a mastectomy-but we'll have to boot you out of your bed before daybreak because that's a half-day-stay-limit on hospitalization!

 

[TXINSURANCE]

Re: Assurant Health - Maternity Benefit - "Normal" Vaginal Delive

Whats the difference when there is a separate maternity deductible anyhow?

 

[HealthGuy]

Re: Assurant Health - Maternity Benefit - "Normal" Vaginal Delive

I want the Pelosi Plan just passed to cover all vaginas. As a feminist (look at my hairdoo) this is just an injustice. I want 100% coverage for all vaginas.

 

[IndividualHealthGuy]

Re: Assurant Health - Maternity Benefit - "Normal" Vaginal Delive

I want the Pelosi Plan just passed to cover all vaginas. As a feminist (look at my hairdoo) this is just an injustice. I want 100% coverage for all vaginas.

Except at bachelor parties?