Excellus BCBS lying to me at every turn

I am utterly beside myself at what Excellus is putting me through.

I called them this Spring about 3-4 times inquiring about coverage for a surgical procedure I needed to have done out of the country. I very clearly stated my intentions and the reason why I needed to have this done by a specialist surgeon in another country. Every time I called the customer service person told me the surgery would be covered. They stated to me multiple times variations of:

-“You are covered by our Global Core program”

-“It’s illegal to deny claims. Just make sure you submit all the required documents and you’ll be covered”

-“We can not deny pre-existing conditions, you will be covered”.

The last person I spoke to even emailed me instructions on how to submit an international claim form for when I get back. So I went ahead and took out a $40,000 loan and paid for the surgery myself out of pocket and got the surgery done.

I submitted my international claim two weeks after the surgery and the games with Excellus began right away. I had to resubmit it four times because each time they claimed some paperwork was missing even though it was clearly included in my email attachments. After my 3rd submission I got on the phone and the person verbally confirmed they have everything they need. Despite that I called a few weeks later to check on status of the claim and it wasn’t being processed again due to “missing information”. So finally after the fourth time resubmitting they accepted the submission.

8 weeks goes by and I haven’t heard a word from them so I call again to check on the status and they tell me it was denied several weeks ago. I asked why and at this point the company began pulling a COMPLETE 180 on me. They now started stating reasons the surgery isn’t eligible for coverage that they never told me about before:

-“Global core only covers emergencies not elective surgeries”

-“This was medical tourism which isn’t covered”

-“You needed prior authorization for this”

NONE of those things were ever mentioned to me prior to my surgery despite me calling repeatedly to verify my coverage. They completely flipped the script on me. I of course told them about the glaring contradiction going on here and asked to file an appeal and asked about how the appeal process would work in this case. They assured me repeatedly over the phone that:

-“We will review the recorded phone conversations that you placed with us in the Spring. If we told you at that time that the surgery would be covered then we will honor what we said”.

At this point I’m angry about their conduct and feeling really foolish for not demanding a written letter guaranteeing coverage prior to my surgery. I’m also feeling stupid for not at least recording my phone calls with them. Taking them at their word alone, even though it was crystal clear and repeatedly stated, was a big mistake. Now I am in a situation where I am completely relying on their integrity to honor what they told me over the phone. I thought that the phone conversations were crystal clear and would assure they would approve the claim now.

Another 5 weeks goes by and still I hear nothing. I’m not getting any letters in the mail, phone calls, emails, nothing. So I call again and they said the appeal was denied again for the original reasons:

-“The Global Core program only covers emergencies not elective surgeries”

-“This was medical tourism”

-“You needed to get prior authorization”

I escalated the call to a manager and demanded an explanation for how this could of possibly been denied again after listening to the record phone calls because the calls clearly stated that Excellus would cover the surgery. The only thing the manager could tell me was that there was a note in the file stating they oppose what I assert was said during the phone call. I can not possibly fathom how they could disagree with what I was told on the recorded calls. I asked to speak to the person who made the determination and was told no. I asked for a copy of the recorded phone call and they wouldn’t give me those either.

So now they said they are filing a “Grievance” appeal on my behalf. I can no longer trust anything they tell me and I have zero confidence in their integrity. I feel so stupid because the ball is fully in their court and they are seemingly doing and saying whatever they want and not giving me any explanations for anything.

Can anyone tell me what I can do to help my case? Should I be preparing for a legal battle? What recourse do I have since I don’t have the record phone calls or a written letter guaranteeing coverage?

Their conduct is unbelievable.