We've all heard stories about health insurance companies refusing to budge after denying a claim, often asserting that the policyholder was in the wrong.
David Cienfuegos said his wife was told by Anthem Blue Cross that his doctor was part of the insurer's coverage network, but then was left with the tab for about $5,800 in medical costs after Anthem insisted that it never said any such thing.
In this case, though, Cienfuegos, 40, has a digital recording of the Anthem rep clearly saying his surgery would be covered.
And he's suing to hold the insurer accountable.
"It's shameful," Cienfuegos told me. "It's like they have a policy of denying claims without even looking at the facts."
He said his wife contacted Anthem on Sept. 10 to make sure that surgery for a condition known as varicoceles, which can cause infertility in men, was covered under the plan and that his doctor, Philip Werthman, was in Anthem's network.
Having received verbal assurances on both counts, Cienfuegos said, he underwent surgery at a Los Angeles clinic and submitted a claim to Anthem on Oct. 28.
The company denied full coverage for the claim on Dec. 2, he said, ruling that Dr. Werthman was not part of Anthem's network. Any reimbursement Cienfuegos received thus would be at a lower out-of-network rate.
Cienfuegos appealed the decision, saying he and his wife had been assured by an Anthem rep that the doctor was indeed in-network. The couple included with their appeal a compact disc of the recording they'd made of the original exchange.
"Anthem says it can record calls for quality-assurance purposes," Cienfuegos explained. "So we did the same."
But on Feb. 19, Anthem once again denied full coverage of the claim, insisting that Cienfuegos was never told that his doctor was in-network or that his operation would be covered.
This was an intriguing position for the insurer to stake out, considering that the recording Cienfuegos had submitted appeared to contradict it on both points.
Cienfuegos' lawyer, William M. Shernoff, shared the recording with me. Cienfuegos' wife can be heard speaking at length with an Anthem rep who identifies himself as Howard.
Here's a portion of their conversation, which is also included in the lawsuit:
Wife: So how can I find out if the doctor we're working with is contracting with Anthem?
Howard: If you know the doctor's name, I can look them up for you.
Wife: The doctor who is doing the procedure … is Dr. Werthman, W-e-r-t-h-m-a-n.
Howard: Philip?… Yes, that doctor is in-network.
Wife: Oh, OK. So when I submit my claim form, that goes towards the in-network deductible?
Howard: Correct.... That is correct.
Wife: I just wanted to then confirm that the procedure, veri — I'm sorry, what was it called again? I know I gave you the name.
Howard: Uh, varicocele. I am not quite sure how you pronounce it.
Wife: Varicocele. That's covered by our insurance?
Cienfuegos, who said he works as a real estate investor, asked that his wife's name be withheld for privacy reasons.
In its Feb. 19 letter rejecting Cienfuegos' appeal, Anthem said the company's own records show that "no specific provider was mentioned in the conversation nor was it noted you were misinformed about participating status for this specific provider in question."
That's just b-i-z-a-r-r-e.
Cienfuegos' wife can be heard on the recording spelling out the provider's name, and the Anthem rep can be heard confirming both his in-network status and that the procedure would be covered.
"The tape is real clear," said Shernoff, Cienfuegos' lawyer.
Darrel Ng, an Anthem spokesman, said the company could only comment in detail if Cienfuegos signed a form waiving his federal medical-privacy rights. Cienfuegos declined to do so.
But Ng provided a statement suggesting that the insurer is open to the idea that its service rep messed up.
"If Anthem determines that a customer service representative has erred when providing a member information about the network status of a provider," he said, "Anthem will remedy the situation and pay benefits as if the provider was in network."
Ng declined to elaborate when I asked how a service rep also could be responsible for the claims department contradicting the contents of the recording.
Shernoff said he expects Anthem to settle the lawsuit out of court. "Anthem couldn't go to a trial on this," he said. "They'd get killed by a jury."
Legal maneuvering aside, there are obvious lessons here for all businesses.
Make sure your service reps are well trained. Make sure they're working with the best available information. If for any reason a rep misleads a customer, don't hesitate to make things right.
And when a customer sends in a CD with a recording of a questionable exchange, make sure you listen to it. Otherwise, the next letter you receive will probably be from a lawyer.
David Lazarus' column runs Tuesdays and Fridays. He also can be seen daily on KTLA-TV Channel 5 and followed on Twitter @Davidlaz. Send your tips or feedback to firstname.lastname@example.org.Copyright © 2015, Los Angeles Times