Maternity Insurance Coverage Buried In Fine Print

Freelance journalist Sarah Wildman believed her individual insurance policy would cover 100 percent of her maternity costs. But even with coverage, Wildman's bills amounted to more than $20,000. She recently wrote about getting duped by the "fine print" and the ensuing battle with her insurance provider. Wildman talks about her experience, as featured in the online publication Slate.com.

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MICHEL MARTIN, host:

I'm Michel Martin and this is TELL ME MORE from NPR News. Coming up, there are collectors and then there is Samu Qureshi, who's amassed what's believed to be the largest collection of memorabilia from the storied Washington Redskins football franchise. From these mementos he's pieced together an interesting story about the team's and the nation's troubled racial history. That story in just a few minutes.

But first, we're continuing our conversation about health care. Earlier we heard from freshman lawmaker Jim Himes about how Congress is dealing with the battle to overhaul health care. Now we turn to a personal story about an issue at the center of the debate, health insurance. Freelance journalist Sarah Wildman recently gave birth to a baby girl. She and her partner, both self-employed, were paying for their own health insurance policy which they assumed would cover much of the expense. But once the bills came in the couple were told they owed more than $20,000. How did that happen? Sarah Wildman wrote about her experience in an article being published today at Slate.com and she's here with me in our Washington studio. Welcome, thank you for coming.

Ms. SARAH WILDMAN (Freelance journalist): Thank you for having me.

MARTIN: And congratulations.

Ms. WILDMAN: Thank you.

MARTIN: So you and your partner, like some 21 million other self-employed and unemployed Americans, are paying for your insurance out of pocket. Did you have any trouble, first of all, finding a provider?

Ms. WILDMAN: We came back from Europe. We lived in Europe for a few years where actually my partner did his MBA and I was working for the New York Times and The Guardian and a few other places. And of course, insurance there is almost free and it's very comprehensive. We came back and looked to purchase a policy and we thought we might want to have a baby, so we wanted to add a policy to that. And in fact it's extremely difficult to find a policy on the individual market that includes maternity.

We asked around. We talked to people. We did a lot of research and we bought a policy and tacked on an extra $126 a month to be able to have a baby. In fact, if we had not done that, we would have had a 10-month waiting period and if I'd gotten pregnant without it, I wouldn't have been allowed to buy it. So we bought from CareFirst Blue Cross Blue Shield. We were told we would be covered. We thought we'd read everything. We consider ourselves to be educated people. We thought we'd looked into it and we weren't covered.

MARTIN: How did that happen? How is it that you weren't covered, even though you were specifically paying a rider to cover your pregnancy? And I do want to mention, even though it's none of our business, but you do mention in the piece that this was a forethought. This was not a situation where it's a preexisting condition - that this was all done according to the timeline that people say you're supposed to.

Ms. WILDMAN: We really thought we'd investigated it. We knew that you couldn't buy into a plan after you'd purchased a plan. CareFirst Blue Cross Blue Shield has a plan, you can add an additional rider for $126. You cannot buy that plan after you've started the policy. If you get pregnant, it is a preexisting condition. The fetus is a preexisting condition. And in fact, when I first got pregnant, the obstetricians told us it was a preexisting condition, I was not covered. And we actually fought at the beginning for that.

So let me clarify. The $25,000 includes what we paid out of pocket per month, also in tests, in deductibles; we had high deductibles. We thought we were paying into it. We almost thought it was like a layaway plan for having the labor and delivery covered. And what I mean by not being covered and what I mean by not knowing it was that there in fact was a cap.

MARTIN: What was the cap?

Ms. WILDMAN: It was a $3,000 cap per pregnancy, which meant that that had to cover all prenatal care, all tests, all sonograms, hospital and delivery, anesthesiology if I used it...

MARTIN: Is there a hospital delivery that can cost $3,000? Does it exist?

Ms. WILDMAN: It does not exist in America. The average normal vaginal delivery in America costs $7,500. That's nationally. So I'm not talking about D.C., New York City, those are likely higher, just like everything else.

MARTIN: And you wound up having a Cesarean which happens sometimes after, you know, hours in labor if things aren't progressing, doctor makes a decision that this is the best thing to do. And typically how much does a Cesarean cost?

Ms. WILDMAN: $13,500.

MARTIN: So there was no way this policy was going to cover the cost, the actual cost of having this baby.

Ms. WILDMAN: There was no way and CareFirst admitted that afterwards.

MARTIN: So what did you do?

Ms. WILDMAN: I thought it was a joke. I'll tell you the truth. When I saw the bill, I thought, oh, that's funny. I mean, that's, you know - here's a zero next to my insurance policy and in fact there's clearly been an administrative slip-up. We'll call them. It'll get straightened out. And we called and called and the hospital called us and called us and we got nowhere.

MARTIN: What do you mean the hospital called you and called you?

Ms. WILDMAN: Well, we started getting creditor bills.

MARTIN: Calls from...collections?

Ms. WILDMAN: Yeah, from the billing department and they said, we're turning this over to collections. Now, we don't own our own home. We would like to buy one eventually, or an apartment. And we didn't want this on our credit report so we fought them. We said, please, please, put this on hold. We know CareFirst made a mistake. We kept calling CareFirst and CareFirst never told the hospital that they were even reviewing the claim.

So that was part of the problem. The hospital said, you say they're reviewing the claim but we don't know that. So we called and called and called. This took us about five months. In the beginning of June, once I decided I would write a story about this - because I basically saw this as an example of, you know, everybody's talking in the media right now about what's in health reform for the middle class? What's in it for us?

And in fact I think I was one of those people - not that I didn't think what's in it for me because I thought - I think that health insurance is a right, but in fact I did in retrospect think of it as something distant from myself. I didn't realize I was a part of the conversation. And I think if Americans realized, as I do now, that maternity is not covered for everyone, that maternity is not considered essential care, that might actually open up the conversation a little bit.

MARTIN: So tell me what happened when you started writing about this?

Ms. WILDMAN: We called again and again customer service, got nowhere. They wouldn't pass us on to supervisors. They said, I'm sorry, there's nothing we can do. When I called the press department and I said, I'm writing about how you sold me a fraudulent policy. You said this covered labor and delivery. It got me no further than in the door. It didn't cover the admission into the hospital, so how could you call this a maternity policy? And the guy said, well, you know, I'm going to pass you to customer service and I got passed up the food chain to someone at the very top in Baltimore, a wonderful woman who was totally lovely and said to me, you're right, it's not a good policy. I'm going to look into it and see if there's something we can do. And so she looked into it and within a week, after six months of fighting, all of a sudden we got a call saying CareFirst was covering 90 percent of our hospital bill.

MARTIN: In fact, we called CareFirst and asked for a response from them in response to your piece and we got this statement. We'll post it on our Web site as well and it says - I'll read it. We worked diligently with Ms. Wildman to address and resolve any issues related to her coverage.

So there you have it. What do you think happened here? Is it the prospect of unflattering publicity that caused them to change the policy or do you think it's just because you were diligent in fighting it?

Ms. WILDMAN: I think it's a combination of the two. I spoke to a lot of policy analysts during the process of fighting this claim and writing the story. Karen Pollitz is director of the Health Policy Institute of Georgetown University, said to me, a lot of people don't fight. And in fact, had our bill been $1,000, would I have spent six months fighting it? I'm not sure. It wouldn't have necessarily been worth the time. But for a $12,000 bill, yes, it would.

MARTIN: But that information was in the policy though, right?

Ms. WILDMAN: You're right.

MARTIN: And where was that information?

Ms. WILDMAN: It was in the addendum book which was a list of appendices, so very thick, couple hundred pages long, somewhere in the middle there, in a table it said extended maternity policy, an asterisk, this is capped to $3,000.

MARTIN: Did you get that information up front or did you only get that information after you had already bought the policy?

Ms. WILDMAN: We got the information after we bought the policy. And I think that's the case for a lot of Americans. And in fact, there are no laws that require individual coverage to tell you exactly what you're getting.

MARTIN: So what is your takeaway from this besides this gorgeous baby girl?

Ms. WILDMAN: I'm extremely blessed with the baby girl. She's fantastic.

MARTIN: But how has this experience affected you?

Ms. WILDMAN: It's been trying, for one, but - and I know Americans don't like to be compared to Europe, but in Europe there are incentives to have children. This is a disincentive to have children. Who are we as a society if we're not going to cover maternity care, if we're going to allow a couple to go into debt? I think the takeaway for me was, we are all affected by this health insurance problem. We are all a part of the health care reform debate and while 63 percent of Americans receive employer-based insurance, 14,000 people lose it every day, and what happens then?

Okay, it's expensive, but should it also not be comprehensive? That's what I didn't realize. It's not comprehensive. It does not cover what it says it covers. We should have something that allows us to know what we're buying. Karen Pollitz had a great quote in a Consumer Reports piece about individual market recently when she said, rice is rice and gasoline is gasoline but what is health insurance? And in fact we don't know.

MARTIN: Sarah Wildman is a freelance journalist. She wrote a firsthand account of her battle with the insurance industry over her recent pregnancy. You can find that report in Slate.com today. Sarah Wildman is here with me in Washington. Thank you so much.

Ms. WILDMAN: Thank you for having me.

MARTIN: Remember at TELL ME MORE the conversation never ends. Now we'd like to know has this ever happened to you? Have you paid for health insurance only to find that essential parts of your care were not covered? What did you do about it? To tell us more please call our comment line at 202-842-3522. Again, that's 202-842-3522, or you can go to our Web site, that's the TELL ME MORE page of the new npr.org and blog it out.

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Statement from CareFirst BlueCross BlueShield:

We worked diligently with Ms. Wildman to address and resolve any issues related to her coverage.

-Kevin Patrick Kane, Media Relations, CareFirst BlueCross BlueShield

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