• Insurance Carrier: Wellmark Bluecross Blueshield
  • State: IA

Consumer Complaint:

After quitting my job to be a stay at home mom, my son and I needed to move from our group insurance to an individual insurance policy (same insurance company). I was accepted. My 5 month old son, who had a brief stint in the NICU, was denied. The insurance company cited \”multiple medical issues\” as the reason for the denial. I called customer service and was told that specifically it was the diagnosis of respiratory distress syndrome that derailed his acceptance. My son never had respiratory distress syndrome. I contacted doctors and had letters written by his neonatologist and pediatrician. I included the discharge summary from the hospital. All evidence was clear and decisive that my son never had this condition. The doctors and his medical records all indicated that he was in excellent health currently and that his long-term prognosis was great. Less than four hours after the appeal was submitted, I heard that the insurance company was sticking with the denial.

Insurance Expert Answer:

As the laws governing what health insurers and HMO plans can and cannot do when underwriting an application for coverage vary considerably from state to state, and it would take an expert in your state's laws to be able to give you a definitive answer, other that provide some general guidance, we are not going to be able to assist you with this matter.

The problem you have presented is just one more illustration as to why our nation needs, more than ever, a national health insurance plan providing basic medical coverage for all, to replace or supplement the largely employer based system we have now.

The first general suggestion we can make is to join a group that enables you to have coverage without any underwriting for yourself or your dependents. Individual plans are almost always underwritten, and plans aim to weed out those applications that their experience demonstrates have a greater than average likelihood to produce what would be a major claim, even if the chance of a claim is still small. Second, contact your state insurance department (or the other regulator of the health plan in question) and seek its assistance. Third, do what you can to help bring about a national health insurance plan. We need one.