My brother, John, who is self-employed, 58, single and lives in California was on a several month long RV camping trip hundreds of miles away from his home when he was diagnosed with bladder cancer this past February. All of his family (parents, siblings) are on the east coast and we urged him to come east so that we could provide support and care for him through the required treatment.
Pondering that possibility, he called his health insurance company, Healthnet (CA) to determine what the consequences of obtaining treatment in Pennsylvania would be. He was told that the only difference in coverage would be that instead of having an annual $3,500 deductible requirement and co-pays, his deductible for out-of-network treatment would be $5,000. He thought being near family was worth the extra $1,500 OOP and we (his family) agreed.
He has been a Healthnet subscriber paying premiums to them for about 10 years and in that time never had a claim that exceeded his deductible.
Consequently, based on his numerous inquiries to Healthnet, John did come to PA, had consultations with doctors from UPMC (U of Pitt Medical Center); two surgeries, six BCG chemotherapy treatments over the course of 5 months. UPMC was also in contact with Healthnet, verified to their satisfaction, based on the information that Healthnet of CA gave them that John was covered for the procedures and care they were about to provide. UPMC proceeded to collect the necessary co-pays for each admission to the hospital and the office visits, etc...
Once the bills began to come in, Healthnet denied the claims stating that John's treatment for this obviously covered condition was only $1,000 day for inpatient care and there were only two inpatient hospital days. John has received bills for over $65,000 so far and more are coming. John appealed the denial. He received the final denials (from Healthnet) of his claims this week. He has appealed to the insurance commission in CA. UPMC has begun collection efforts even though they agree that Healthnet gave both John and them assurances he was covered.
Buried in the 70 page insurance policy....some 23 pages after the statement that out-of-network care requires a larger maximum annual OOP, is a small clause stating that out-of-network treatment coverage is limited to $1,000/day for in-patient care. Due to the fact that surgery for bladder cancer is scheduled as an out-patient procedure and John required only one day beyond the out-patient
surgery day, Healthnet has paid only $750 on one claim so far.
Faced with the denials, John returned to CA, and recently learned that the chemo treatment was not successful. He has to have his bladder removed. He is receiving treatment in-network now and will have the surgery to remove his bladder and make a new one on October 11th. Healthnet is covering this additional treatment.
My question is this: Is this not a case of bad faith on the part of Healthnet? How could anyone diagnosed with cancer while hundreds of miles from home, without the 70 page copy of their health insurance policy in hand determine their coverage other than calling their insurance company? How could he have possibly known that what the Healthnet representatives told him and UPMC was untrue? Could it be that Healthnet deliberately gives their customers erroneous assurances of coverage to mislead them so that Healthnet can deny coverage in what they would otherwise have to pay?
John has requested the recordings of his conversations with Healthnet and has received nothing. He suspects they have been destroyed or are being withheld because they prove that what he is saying is correct.
I know that Healthnet lost a huge lawsuit recently due to rescinding policies unfairly. This situation seems at least as egregious. John's treatment would absolutely be covered had he been in network. And there would have been no $1,000/day limit. Ironically, the care received in PA was less expensive than the same care John would have recieved in CA.
Are any agents here familiar with Healthnet of CA and/or have experience with similar cases (and willing to share it)? Any advice of how to proceed? John is sick, weakened by his condition and now emotionally battered by this experience with Healthnet. He is currently pretty well beaten down to a nub. I know that he doesn't have the strength at this point to institute a lawsuit....but I sure think that he has grounds for one. How can the people running that company sleep at night?
Pondering that possibility, he called his health insurance company, Healthnet (CA) to determine what the consequences of obtaining treatment in Pennsylvania would be. He was told that the only difference in coverage would be that instead of having an annual $3,500 deductible requirement and co-pays, his deductible for out-of-network treatment would be $5,000. He thought being near family was worth the extra $1,500 OOP and we (his family) agreed.
He has been a Healthnet subscriber paying premiums to them for about 10 years and in that time never had a claim that exceeded his deductible.
Consequently, based on his numerous inquiries to Healthnet, John did come to PA, had consultations with doctors from UPMC (U of Pitt Medical Center); two surgeries, six BCG chemotherapy treatments over the course of 5 months. UPMC was also in contact with Healthnet, verified to their satisfaction, based on the information that Healthnet of CA gave them that John was covered for the procedures and care they were about to provide. UPMC proceeded to collect the necessary co-pays for each admission to the hospital and the office visits, etc...
Once the bills began to come in, Healthnet denied the claims stating that John's treatment for this obviously covered condition was only $1,000 day for inpatient care and there were only two inpatient hospital days. John has received bills for over $65,000 so far and more are coming. John appealed the denial. He received the final denials (from Healthnet) of his claims this week. He has appealed to the insurance commission in CA. UPMC has begun collection efforts even though they agree that Healthnet gave both John and them assurances he was covered.
Buried in the 70 page insurance policy....some 23 pages after the statement that out-of-network care requires a larger maximum annual OOP, is a small clause stating that out-of-network treatment coverage is limited to $1,000/day for in-patient care. Due to the fact that surgery for bladder cancer is scheduled as an out-patient procedure and John required only one day beyond the out-patient
surgery day, Healthnet has paid only $750 on one claim so far.
Faced with the denials, John returned to CA, and recently learned that the chemo treatment was not successful. He has to have his bladder removed. He is receiving treatment in-network now and will have the surgery to remove his bladder and make a new one on October 11th. Healthnet is covering this additional treatment.
My question is this: Is this not a case of bad faith on the part of Healthnet? How could anyone diagnosed with cancer while hundreds of miles from home, without the 70 page copy of their health insurance policy in hand determine their coverage other than calling their insurance company? How could he have possibly known that what the Healthnet representatives told him and UPMC was untrue? Could it be that Healthnet deliberately gives their customers erroneous assurances of coverage to mislead them so that Healthnet can deny coverage in what they would otherwise have to pay?
John has requested the recordings of his conversations with Healthnet and has received nothing. He suspects they have been destroyed or are being withheld because they prove that what he is saying is correct.
I know that Healthnet lost a huge lawsuit recently due to rescinding policies unfairly. This situation seems at least as egregious. John's treatment would absolutely be covered had he been in network. And there would have been no $1,000/day limit. Ironically, the care received in PA was less expensive than the same care John would have recieved in CA.
Are any agents here familiar with Healthnet of CA and/or have experience with similar cases (and willing to share it)? Any advice of how to proceed? John is sick, weakened by his condition and now emotionally battered by this experience with Healthnet. He is currently pretty well beaten down to a nub. I know that he doesn't have the strength at this point to institute a lawsuit....but I sure think that he has grounds for one. How can the people running that company sleep at night?
Last edited:
