I doubt I am the “member of the month” for Blue Shield of California. Since my breast cancer diagnosis at a young age, the costs of my surgeries, medications, tests, and doctor visits have likely soared into the millions.
In the United States, we are fortunate to access some of the finest healthcare available. As a breast cancer survivor, I depend on cutting-edge technology, thorough testing, and ongoing research, working alongside my medical team to determine the best path to ensure I see my children graduate. Yet, the healthcare industry operates as a billion-dollar enterprise that often prioritizes profits over providing affordable and accessible treatment to its members.
Despite having a top-tier Blue Shield of California PPO plan with a hefty monthly premium, I still find myself paying out of pocket for numerous tests and medications each month. What I do not expect is to have to battle Blue Shield of California for the coverage they are legally required to provide.
According to the American Cancer Society, the Women’s Health and Cancer Rights Act (WHCRA) protects women with breast cancer who opt for breast reconstruction following a mastectomy. This federal law mandates that most group insurance plans covering mastectomies also cover reconstruction, a law that has been in effect since October 21, 1998, overseen by the Departments of Labor and Health and Human Services.
Recently, I faced a denial from Blue Shield of California just two days before my scheduled revision surgery for a double mastectomy on February 4th, coinciding with International World Cancer Day. The stress and anxiety surrounding this significant surgery were compounded by the feeling that the denial was a direct violation of the WHCRA.
I was left with two choices: delay my surgery and let my doctor’s office handle the appeal, or fight the denial myself. After weeks of mental and logistical preparations, I chose to fight. I was furious—not only about having cancer, but also about the loss of my womanhood, the repeated surgeries, and the fact that my children were worrying about me once again. Most frustrating was the realization that my healthcare provider, for whom I pay a substantial amount each month, was letting me down.
With just 24 hours before my surgery, I decided to take a radical approach. I tracked down the names of Blue Shield of California’s leadership team and emailed them my concerns. Almost immediately, five executives responded, expressing their concern and promising to escalate the issue.
Over the next six hours, I worked tirelessly with a patient liaison named Alex, who was instrumental in collaborating with both the Blue Shield doctor who had denied the surgery and my own physician. After a peer-to-peer call discussing the medical necessity of my case, my surgery was approved—just 14 hours before my scheduled hospital check-in.
Although I quickly shifted gears to prepare for the surgery, I was still left with a sense of anger. I was frustrated that such a critical process was so complicated. My heart ached for other breast cancer survivors who might not have known their rights or lacked the energy to fight for their entitlements. Many women may not have the luxury of time to engage in such battles.
In light of this experience, I sent another email to the leadership team. While a few executives thanked me for bringing the matter to their attention, I have nine crucial points I want Blue Shield of California to consider:
- My breast cancer diagnosis was not elective; it was devastating news.
- I should not need to fight for medically necessary treatments and procedures.
- I shouldn’t have to cite federal law to validate my entitlement to coverage.
- I worry for other women who might not possess the know-how or energy to advocate for their rights.
- It took some simple color photographs to secure immediate approval for my surgery. Instead of sending a stark denial letter, consider a more empathetic approach that requests additional information.
- Alex, the liaison who assisted me, was remarkable in showing empathy and care. More individuals like him should represent your organization instead of sending impersonal denial letters.
- While I appreciate the correction of this oversight, it raises questions about the motives behind denial letters that could save your company substantial sums of money.
- Please learn from this failure and make the necessary changes to provide healthcare and communication that reflect the value you place on your members.
- As a cancer survivor, I will require ongoing testing and procedures. I hope I will not have to fight for my coverage again, as it exhausts me both mentally and physically.
I hope you never find yourself in a position where you must fight for healthcare. But if you do, and if you find your insurance company lacking, reach out to the proper regulatory agency overseeing your plan. In California, the DMHC and CDI can assist you.
Blue Shield of California responded: “We cannot comment on any member case due to federal privacy laws. However, we take access to care for our members very seriously and will always work with them to ensure they receive the care they need.”
For further reading on your rights, check out this excellent resource for pregnancy and home insemination at ACOG. You can also learn more about related topics at Home Insemination Kit and Intracervical Insemination.
In summary, my experience highlights the urgent need for healthcare providers to prioritize patient care over profits. The system must change to ensure that all patients, especially vulnerable survivors, receive the coverage they deserve without having to fight for it.