Hello everyone,
I live in NJ but work for a large company based in California (10k employees) My insurance company is BCBS California (suitcase icon)
In 2021 a family member visited the emergency room in NJ with a serious face injury. He was treated in the emergency room by a plastic surgeon (face surgery) and was released after several hours. He was not admitted to the hospital. It turned out although the emergency room was in network the plastic surgeon wasn’t (very common here). Insurance covered the emergency room but was only willing to cover a fraction of the surgeon claim. The claim was 45k, but insurance is only paying 500, leaving us responsible for the rest. We’re not covered under the NJ balance billing law since this is a self funded plan.
I filed an appeal, but it was denied. With the denial letter I received a copy of the full policy (150 pages). The part discussing emergency room coverage basically says:
If the emergency room is in California, insurance company will pay the customary and usual rates for out of network providers and you’re not responsible for any balance left. But outside California, they will only pay the max allowed (500 dollars in this case), and you’ll be responsible for this rest.
Is this even legal? Can an employee offer different coverage in different states? Other than this, anything can be done? 45k is really a ridiculous amount of money. Thanks.
submitted by /u/Global_Sink_125
[link] [comments]Hello everyone, I live in NJ but work for a large company based in California (10k employees) My insurance company is BCBS California (suitcase icon) In 2021 a family member visited the emergency room in NJ with a serious face injury. He was treated in the emergency room by a plastic surgeon (face surgery) and was released after several hours. He was not admitted to the hospital. It turned out although the emergency room was in network the plastic surgeon wasn’t (very common here). Insurance covered the emergency room but was only willing to cover a fraction of the surgeon claim. The claim was 45k, but insurance is only paying 500, leaving us responsible for the rest. We’re not covered under the NJ balance billing law since this is a self funded plan. I filed an appeal, but it was denied. With the denial letter I received a copy of the full policy (150 pages). The part discussing emergency room coverage basically says: If the emergency room is in California, insurance company will pay the customary and usual rates for out of network providers and you’re not responsible for any balance left. But outside California, they will only pay the max allowed (500 dollars in this case), and you’ll be responsible for this rest. Is this even legal? Can an employee offer different coverage in different states? Other than this, anything can be done? 45k is really a ridiculous amount of money. Thanks. submitted by /u/Global_Sink_125 [link] [comments]Read Morer/HealthInsurance