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Complaint 0 of 0 in "Experimental Treatment"

Insurance Carrier: Empire Blue Cross/Blue Shield
State: Pennsylvania

Consumer Complaint:

In December 2007 I had a mammogram with suspicious results. This resulted in the need for an ultrasound which was also inconclusive. I visited a specialist who ordered a breast MRI in January 2008. Before getting the MRI the doctor's office (while I was present) called the insurance company to get precertification. They said no precertification was necessary. Now in June I find out they are denying the claim because they say the breast MRI is experimental and I should have had a biopsy instead. The insurance company was aware of the type of MRI and the purpose and did not mention at that time of the phone call that they considered the MRI experimental and would not pay for it. I know I can appeal the claim, but I want to know if this process is an act of bad faith. The call was made to specifically determine coverage and I believe they should have told me before I had it done that it wouldn't be covered. I am also interested in knowing if there are any current class action suits against Empire for cases such as this.

Insurance Expert Answer:

If your health plan was provided through a private employer, it is immaterial whether or not it involved bad faith. While the existence of bad faith could be a basis for potential punitive damages in a case of a private insurance policy, the ability of any party to sue for punitive damages was eliminated by Congress when it comes to employee benefit plans covered under ERISA.

As to whether or not any particular diagnostic test is experimental, you may want to check the website, and the literature on other medical sites. One reason insurance plans reject "experimental" diagnostic tests is that experience shows that they are far more expensive standing alone, or often require the conventional diagnostic test in an unduly high percentage of circumstances. If test 1 often yields inconclusive results, and in such cases still requires the traditional test 2 to be performed, the insurance company's aggregate cost is thus much higher.

One approach that may work -- if the facts are as postulated below -- is to explain that 1) that the so called "experimental" MRI test you had was less costly than the conventional biopsy would have been, and 2) it avoided the need and expense of performing a biopsy. In other words, the company saved money because a less expensive alternative worked in your case. We have no information on relevant class actions suits.