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/LizzieMac123 Moderator Apr 11 '25

AI is wrong here. The SBC- summary of benefits and coverages- is the summary of benefits, the SPD is 100+ pages and goes into detail on what's covered or excluded.

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u/Janknitz Apr 11 '25

An SBC is not necessarily complete: "The SBC provides a partial list of services that the plan does not cover. For example, services such as adult dental care, infertility treatment, long-term care, or cosmetic surgery might not be covered. However, because the list of services that are not covered might be incomplete, you should contact the plan directly and ask for a list of all of the services that the plan does not cover. " https://nationaldisabilitynavigator.org/ndnrc-materials/fact-sheets/fact-sheet-1/

Many states, including my state of California, require even employer provided plans, to provide the EOC on request. A "summary" is not the contract, and is not necessarily complete. When denials occur, the insurer must provide the basis for the denial. If that basis is not stated in the contract (EOC) then it does not apply. When something is not stated in the Summary, you still don't know for certain what the insurer's obligations are with respect to coverage, except what they tell you, and that is NOT reliable. I have seen insurers claim something is excluded when it is not. That was proven by the failure to list a particular exclusion in the EOC. When pointed out, they had to pay up.

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u/LizzieMac123 Moderator Apr 11 '25

I'm just going to leave this here: https://www.caravus.com/blog/2017/09/28/qa-spds-plan-documents-eocs

SPD is the main document participants should use to look at coverage. EOC/Certs and SBCs do have some information too- all are plan documents.

But the SPD is not a summary like AI says that's the SBC- that's all I was saying- example here: https://www.bcbstx.com/sbc/ind/sbc-ghsa01bftitxo-tx-2025.pdf

ERISA requires the SPD be given to participants and often INCLUDES the EOC as a reference document/addendum. But the EOC on it's own is not the main document.