Summary of Benefits and Coverage Incorrect / Contradicts Actual Policy

Is there anything I can do if the Summary of Benefits and Coverage (SBC) that I received unambiguously states there is no charge for Durable Medical Equipment (DME), and I relied upon that, and now my health insurance (Horizon BCBS of NJ) is pointing to the actual member contract booklet / policy to demonstrate that there is a charge for some items considered (by Horizon BCBSNJ) to be DME?

The exact wording for Tier 1 and Tier 2 providers in the SBC for DME is: “No Charge. Deductible does not apply.” For Out-of-Network (which is not relevant since the DME was provided by a Tier 1 provider), it states “Not Covered.” Under Limitations, Exceptions, & Other Important Information all it states is “Requires pre-approval” – which my Tier 1 provider got. The DME in question is orthotics.

Thanks!

P.S. As requested by AutoModerator – I’m 42, live in NJ (07936), and my income probably puts me in upper middle class (would prefer not to provide specific income info).

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