Health Care Service Corporation, doing business as Blue Cross and Blue Shield of Oklahoma (BCBSOK), is the defendant in a proposed class action lawsuit through which the plaintiffs take issue with, among aspects of their dealings with the insurer, an apparent lack of any explanation as to why the company covered so little of the cost for emergency air transportation for their prematurely-born son. From the lawsuit:
“Plaintiffs, in an emergency situation with their newborn child’s life on the line, were without the luxury of taking the time to identify any in-network air ambulances, if any such air ambulances existed. On information and belief, no in-network air ambulance was available in that location at that time.
“Furthermore, while ordering the emergency air ambulance transfer, the coordinator inquired about Plaintiffs’ insurance, and was informed that they were insured by BCBSOK. There was no mention of the fact that the air ambulance provider was out-of-network or that the air ambulance services would not be covered by BCBSOK.”
According to the lawsuit, the plaintiffs’ son was born premature and without fully developed lungs in January 2014. The lawsuit says the child was quickly moved to the intensive care unit at Great Plains Regional Medical Center in Elk City, Oklahoma, and then, as his condition deteriorated further, transported by emergency air ambulance to Children’s Hospital at OU Medical Center in Oklahoma City. The case says the plaintiffs were billed $49,999 by the helicopter company for the evacuation.
In May 2014, the defendant reportedly sent the plaintiffs an Explanation of Benefits informing them "the amount [the plaintiffs] may owe" for their son’s emergency air ambulance service was zero dollars. The lawsuit goes on to note that “like more of [Blue Cross and Blue Shield of Oklahoma’s] documents,” the statement, despite leading the plaintiffs to believe they owed nothing, ambiguously noted that “your claim has been denied.”
Four months later, the plaintiffs supposedly received another Explanation of Benefits from the defendant in which they were informed Blue Cross and Blue Shield of Oklahoma would cover $2,909.92 for the air transport, and that they were on the hook for the remaining $47,089 because the company that provided the helicopter was out-of-network. After the plaintiffs appealed the defendant’s determination, the case continues, Blue Cross and Blue Shield of Oklahoma increased the amount it would cover for the air transport – an amount that only took care of “a fraction of the bill,” ultimately leaving the plaintiffs to pay the remaining $45,149.14. The suit notes that "no explanation was provided" by the defendant as to why the insurer adjusted the amount and how it determined the new balance.
Arguing they followed every procedure to timely and properly appeal the defendant’s alleged improprieties, the plaintiffs’ suit centers around BCBSOK’s failure to explain the rationale behind its decision to cover so little of their claim. According to the suit, the defendant, with regard to the plaintiffs’ appeals, for instance, left it “unclear exactly which of [the plaintiffs’] many communications with BCBSOK it treated as the appeal.” In its eventual denial, the defendant repotedly included for reference “the ENTIRE Policy Documents,” which the lawsuit argues unreasonably left the plaintiffs to scour “nearly one hundred pages” to determine the “benefit term(s) or rule(s)” on which the defendant based its denial of their appeal. Further still, the plaintiffs say that despite years passing since the initial incident coinciding with the birth of their son, BCBSOK failed to issue a final denial of appeal until December 2017.
The lawsuit then criticizes the defendant's own policy documents, in which the insurer allegedly promised to treat all emergency services as in-network. “BCBSOK’s refusal to provide such coverage is a breach of its contractual obligations owed to Plaintiffs,” the complaint argues.
Not only should their son’s emergency air transportation have been fully covered by the defendant, the plaintiffs claim, but their contract with Blue Cross Blue Shield of Oklahoma ostensibly set the parents with an $18,000 out-of-pocket limit.
“[Blue Cross Blue Shield of Oklahoma] neglected to address the Plaintiffs’ out-of-pocket limit in any of the communications between the parties,” the case reads. “BCBSOK’s refusal to cover or indemnify Plaintiffs the portion of the $45,149.14 [medical transit] bill above the applicable out-of-pocket limit is a breach of its obligations arising under the Policy Documents and other legal duties owed to its insureds.”