r/HealthInsurance • u/Successful_Job5797 • Apr 10 '25

Employer/COBRA Insurance 30k Labor and delivery bill

Location: Baltimore My girlfriend had our son at Mercy Hospital in Baltimore. We’ve been going there the whole pregnancy no issues. We ended up getting a bill for 30k and they told us her insurance didn’t cover anything. She’s on her mom’s insurance plan which is blue cross Oklahoma. Apparently somewhere in the plan it states grandkids labor isn’t covered. Nobody told us or warned us the entire time we went there. Is there anything we can do or any legal action that can be taken? I understand we should’ve read into it more but we had no idea that was a thing.

My post got removed, is there anything legal I can do? Thank you

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u/chickenmcdiddle Moderator Apr 10 '25 edited Apr 10 '25

Review the BCBS OK policy with a fine tooth comb, but this is an extremely common coverage exclusion. You'll want a copy of the "Summary Plan Description" or SPD. Often called the benefits booklet. This document is a long-form, 100+ page document that outlines coverage dynamics--specifically exclusions. This is where you'll want to zero in on. If it's indeed a plan exclusion, there's literally nothing you can do to compel BCBS OK to pay since it was a documented exclusion. Your care team has no way of knowing this exclusion existed prior, which is why you didn't get a heads up.

Moving forward, you can explore whether mom & baby are eligible for your state's Medicaid program (which has retroactive coverage), or you can use the birth of your child as a qualifying life event to get coverage for baby so that their costs are covered / contained.

What's your current household income (gross income--pre-tax / deductions)?

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u/Janknitz Apr 10 '25

Not Summary Plan Description" or SPD. Ask for the EVIDENCE OF COVERAGE document (EOC). That is the actual contract between you and the insurance company, the SPD is NOT.

From AI: "A Summary Plan Description (SPD) is a simplified, easy-to-understand document summarizing the key details of a benefit plan, including health insurance and retirement plans, while an Evidence of Coverage (EOC) provides a more detailed outline of the plan's specific benefits and coverage, including costs, exclusions, and how the plan operates" Crucial info may be missing from the SPD. You need the EOC to appeal a denial.

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u/[deleted] Apr 10 '25

Summary plan descriptions are used in employer plans as the actual contract rests with the employer and cannot be obtained unless there is a lawsuit. The employer is under no obligation to disclose it.

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u/LizzieMac123 Moderator Apr 11 '25

Absolutely not true. The SPD is supposed to be shared proactively with all plan members. It's often IN the insurance portal itself. (I'm a broker and that's often how I get them).

Additionally, rules mandate that if an employee asks for a copy, HR has to provide it within 30 days.

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u/yuricat16 Apr 11 '25

I think the previous commenter is agreeing with you that the SPD is the document OP wants, and that the literal contract between employer and plan is not widely available as the SPD is what is used instead.

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u/LizzieMac123 Moderator Apr 11 '25

WHich one?

Jan is saying AI says the SPD is a simplified document (it's not, that's the SBC) and Outrage is saying the employer doesn't disclose the SPD which is also not correct.

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u/yuricat16 Apr 11 '25

I was referring to Outrage, and I understood that comment to counter Jan’s claim and affirm that SPDs are used instead of the contract/EOC.

A few more words would have made it clearer, but I read it like this, noting my edits:

Summary plan descriptions are used in employer plans [to communicate coverage to members], because the actual contract rests with the employer and cannot be obtained unless there is a lawsuit.

I felt you deserved a response to your question, but I admit this now feels highly pedantic and like I’m belaboring a somewhat meaningless point. I really appreciate all of the work you put into this sub and the excellent and accurate information you provide.

Cheers!

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u/LizzieMac123 Moderator Apr 12 '25

All good my friend- I admit that I don't know everything and it's my goal as a Moderator to be clear. I appreciate the feedback! No harm no foul in my book, friend!