Patient's cut on finger and stuck with bill, too

Q. I am in a point-of-service plan through the Chicago Board ofEducation with Blue Cross/Blue Shield. One Saturday last November,I cut my finger at home. When it was still bleeding four hourslater, I went to the emergency room of the hospital on my plan andwas treated.

The next morning I phoned my insurer and was given aconfirmation number. On Monday morning I received a call from theconfirmation area asking how I was doing; no mention was made tocall my primary care physician. I thought I had dotted every "i" andcrossed every "t" and followed every rule of my plan.

I certainly was surprised when I received an explanation ofbenefits indicating my charges of $252 were going toward a $400deductible. I told the insurance company I thought I was supposedto pay only a $25 emergency visit fee.I was told I was being penalized because I did not call myprimary care physician, and that is the only way to get the highestbenefit offered by the plan. I have put in a review and was againdenied the level of benefits I was seeking. Do I have any furtherrecourse?A. I checked with Blue Cross/Blue Shield about your situationand was told that when you are in a point-of-service plan you must gothrough the primary care doctor in order to receive the highest levelof payment. Even though you called the number on your insurancecard and had an authorization number, the guidelines for maximumpayment were not met.Q. I am seriously considering a new job offer. The problem ismy wife is four months pregnant, and I am afraid if I leave thecompany we will lose our maternity coverage. Would my presentcompany be responsible for the bills, or the insurance carrier of thenew employer?A. If you have been covered by your current plan for at least18 months, you are eligible for benefits under the Health InsurancePortability and Accountability Act. This means your new employermust cover you and your family for all pre-existing conditions theday you become eligible for their plan.You will receive a certificate of creditable coverage to presentto the new insurer. You also must determine that the new plan hasmaternity coverage. Also, check with your current employer todetermine whether you would be eligible for COBRA or similarstate-run programs.Q. I am insured through my company's group plan forhospitalization, major medical and dental. If the company is soldand the new owners do not keep the same medical insurance company, doI lose my COBRA rights?I was told by the insurance carrier that they do not have to bebound by COBRA if they are not the insuring group. If I am insuredunder COBRA and then the successor owners change insurance companies,does COBRA end at that time? Is there any information available thatexplains COBRA options, qualifications and restrictions?A. Call the customer service area of the Department of LaborPension and Welfare Benefits Administration at (312) 353-0900. Theyshould be able to address all of your questions.Barbara Melman is president of Claim Relief, a Chicago companythat helps people with health insurance problems. Write to her atthe Chicago Sun-Times, 401 N. Wabash, Chicago, 60611.