Lehan Drugs

Initial Business Response /* (1000, 5, 2015/05/26) */
On 11/5/14 this customer filled out our Breast Pump Insurance form online. We contacted [redacted] of Illinois on 11/6/14 and were told by their customer service representative, [redacted] that the customer had a plan that gave coverage...

of 100% for 2 breast pumps per year (Call reference # X-XXXXXXXXXX). We then responded to the customer's insurance form with the information we were quoted by the BCBS-IL representative. Because we are aware that it is possible that the insurance provider may misquote the benefits, we included the statement although not a guarantee of payment in the coverage email. This email prompted the customer to purchase the Medela Pump In Style Advanced Starter Set on 11/8/14 to be billed through her insurance. At no point did she mention to us that she had previously contacted her insurance company and had been told that she was not covered for a breast pump by her plan.
We received a denial from BCBS-IL for the claim on 12/10/14 because it is in fact not a covered benefit under her plan. We sent in for a misquote review to BCBS-IL on 1/22/15 (BCBS-IL call Reference #: X-XXXXXXXXXX) requesting that they review the claim and pay based on the misquote of benefits. We checked on the claim on 2/4/15 (BCBS-IL call reference #: X-XXXXXXXXXX) and were told that the claim was still being reviewed/still open. On 3/17/15 we were notified by [redacted] at BCBS-IL that we were denied the misquote review because the member had called prior to the misquote and was told at that time that it was a non-covered benefit (BCBS-IL call reference #: X-XXXXXXXXXX).
[redacted] of Illinois denied the service entirely and stated that the customer was responsible for the entire $299.99 retail cost of the pump plus tax. We took into account that the customer was expecting coverage by BCBS-IL for the breast pump and did not charge her the full retail cost, but rather the amount we are usually reimbursed by the insurance, which is $150.15. We are unable to discount the pump further than we already have.
Initial Consumer Rebuttal /* (3000, 7, 2015/06/04) */
(The consumer indicated he/she DID NOT accept the response from the business.)
I spoke to [redacted] Drugs two times in April and May of 2015 regarding the pending bill. The misquote from BCBS-IL side, that happened on 11-06-2014, and the following appeal process was never mentioned to me during my conversation with Lehan Drugs. In the response obtained through Revdex.com (Revdex.com), for the first time I got a reasonable explanation from Lehan Drugs about what has happened between them and BCBS-IL. Now I at least understand why Lehan Drugs consider it appropriate to bill me for the pump.
I called BCBS-IL on 05-29-2015 and spoke to [redacted]. She claimed that on XX-XX-XXXX BCBS-IL representative told Lehan Drugs that I am eligible for 2 pieces of durable medical equipment per year at no cost for me, but the breast pump is on the list of equipment excluded from coverage. Moreover during my previous call to BCBS-IL on 03-03-2015 (record # X-XXXXXXXXXX) the representative whose name is [redacted] insisted couple of times that nobody ever told Lehan Drugs, that I am eligible for fully covered breast pump. In this situation it is difficult for me to judge who tells the truth and who doesn't, and therefore, I requested BCBS-IL to send me the transcripts of phone calls from XX-XX-XXXX and 03-03-2015. I've faxed an official request for phone records release on 05-29-2015 (case # XXXXXXXXX) and asked BCBS-IL to provide them before 06-05-2015. However according to their policy BCBS-IL has to respond to me within 60 days and when I called BCBS-IL on 06-04-2015, their response was not ready.
I also came to know that I should be eligible for a breast pump according to the new affordable care act (ACA) legislation. ACA considers breast pumps as preventive care, since they help to prevent mastitis and aid breastfeeding, which is very beneficial for overall future health of the child. According to ACA only grandfathered healthcare plans can deny a coverage for the breast pump. BCBS-IL states that my plan is grandfathered. However according to ACA not only the plan has to be grandfathered but also (quote):
1. the plan haven't been changed in ways that substantially cut benefits or increase costs for consumers,
2. notify consumers with these policies that they have a grandfathered plan,
3. have continuously covered at least one person since March 23, 2010
(unquote).
Only if all three conditions are met the healthcare plan can maintain its grandfathered status. The first person in our household who got enrolled into our current healthcare plan was my husband Salil Arora. He was enrolled in August 2010 (means after March 23 2010). He was not notified that his healthcare plan is grandfathered. Hence neither second nor third conditions were met. We are in the process of filing an appeal with BCBS-IL based on this law. The appeal process with BCBS-IL lasts up to 60 days. If the initial appeal is denied I have right to file re-appeal with BCBS-IL or to file an external appeal with Illinois department of insurance.
I hoped that Lehan Drugs as a provider who regularly bills different insurance plans for their services/products is well aware of these ACA regulations. In fact during my call to BCBS-IL on 03-03-2015 [redacted] mentioned that BCBS-IL is still reviewing an appeal case from [redacted] Drugs regarding my breast pump coverage. [redacted] did not specify the details, but I assumed that the appeal was based on ACA law. As it turned clear to me after reading the response from [redacted] Drugs obtained through Revdex.com the appeal was not based on my legal rights to get a breast pump which ACA grants me. Now I am going to file an appeal on my own. Entire appeal process could be much smoother and faster if [redacted] Drugs communicated to me all the issues they had with BCBS-IL right away.
Instead Lehan Drugs chose language of threats and rudeness, which made me involve the Revdex.com to get this case resolved. Recently I received another bill dated 05-26-2015 with a threatening message that if I don't pay within 10 days Lehan Drugs will engage the collection agency or an attorney to pursue the debt. I consider it inappropriate to engage either of those while the charge is in dispute.
Lastly I don't understand why Lehan Drugs sets the retail cost of the breast pump so high - $299.99. I found same model of the pump on Amazon at the price $131.49 (as of 06-04-2015).
http://www.amazon.com/Medela-Advanced-Breastpump-Set-Model-57081/dp/B00IJJRVR4/r...⇄
On ebay it costs even less - $104.00 (as of 06-04-2015).
http://www.ebay.com/itm/Medela-Pump-In-Style-Advanced-Breastpump-Starter-Set-Mod...⇄ /> I wonder what justifies for $299.99 price.
I request that the Revdex.com case between me and Lehan Drugs remains pending until I go through the appeal process with BCBS-IL. I also request that Lehan drug ceases all attempts to collect the charges while the case is being in dispute.
Sincerely,
[redacted].