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Insurer Denies Woman’s Claim: She Should Have Known That Her Bleeding Breast Was Not An ‘Emergency’

By Zaid Jilani  

"Insurer Denies Woman’s Claim: She Should Have Known That Her Bleeding Breast Was Not An ‘Emergency’"

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One of the worst abuses of private insurance companies is the practice of using spurious reasons to deny claims. In April, Rosalinda Miran-Ramirez awoke and found her shirt soaked in blood. Realizing that her “her left breast [was] bleeding from the nipple,” she rushed to the emergency room.

Today, CBS-5 reports that this San Francisco Department of Public Health employee has had her claim denied because her insurance company, Blue Shield of California, didn’t consider her situation to be an “emergency.” Even though her doctor told her it was likely a tumor, Blue Shield said that Miran-Ramirez should have known it wasn’t:

But Miran-Ramirez said the real shock came when her insurance company, Blue Shield of California HMO, which had initially approved the claim for the emergency room visit, reversed course and sent her a new bill three months later requiring her to pay the total charges for that visit: $2,791.00.

Why? Documents from Blue Shield indicate the company had reviewed the case and determined Miran-Ramirez “reasonably should have known that an emergency did not exist.”

“I am like how can they say that it was not an emergency? Like, my breast was bleeding! I am not a clinical person but if your breast is bleeding, for me that’s an emergency,” she said. [...]

So she appealed. And she was denied again. This time Blue Shield told her she hadn’t been in “any acute distress.”

Watch CBS-5′s report:

The sad truth is Miran-Ramirez is certainly not alone in having her claim denied by a major health insurer. The California Nurses Association (CNA), a nurses’ union and health care advocacy group, recently released a comprehensive study of claims denials across California. The study found that the six largest insurers in California rejected 47.7 million claims in the first half of 2009, nearly 22 percent of all claims submitted. The CNA twice successfully lobbied the California legislature to pass legislation that would establish a single-payer universal health care system in the state, only to have it vetoed by Gov. Arnold Schwarzenegger (R-CA).

Last week, in a congressional hearing titled “Between You and Your Doctor: the Bureaucracy of Private Health Insurance,” top insurance executives testified before Chairman Dennis Kucinich (D-OH) that the insurance company practice of denials can be fatal for its customers.

Indeed, such a denial cost 17-year old Nataline Sarkisyan her life in 2007, when Cigna denied coverage for a liver transplant until it was too late. Her mother, Hilda Sarkisyan, came to D.C. earlier this year to lobby for a public health insurance plan that would stop such denials. She told the press, “Insurance companies cannot decide who’s going to live and who’s going to die.”

Following the CBS-5 investigation, Blue Shield agreed to pay for all charges for Miran-Ramirez’s emergency room visit.

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