An Open Letter to Blue Shield of California Health Care

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Dear Blue Shield of California,

I doubt I’m your “member of the month.” After being diagnosed with breast cancer at a young age, my medical costs—including surgeries, medications, tests, and doctor visits—have likely reached astronomical figures.

In the U.S., we are fortunate to have access to top-notch health care. As a breast cancer survivor, I depend on cutting-edge technology and research, trusting that my medical team and I can choose the best path for my survival, so I can witness my children graduate. Sadly, the health care industry often prioritizes profit over providing affordable and accessible treatment for its members.

Despite having a premium Blue Shield of California PPO plan, I still face significant out-of-pocket expenses for various tests and medications each month, in addition to my hefty monthly premium.

What I never anticipated was having to battle Blue Shield of California for coverage that is legally mandated. As outlined by the American Cancer Society, the Women’s Health and Cancer Rights Act (WHCRA) guarantees many women with breast cancer access to reconstructive surgery post-mastectomy. This federal law, enacted on October 21, 1998, mandates that most group insurance plans covering mastectomies also cover reconstruction.

When I was slated for a revision to my double mastectomy, I was devastated to receive a denial from Blue Shield just two days before my surgery, which fell on February 4th, International World Cancer Day. The denial was particularly distressing as it seemed to counter the protections afforded by WHCRA.

Faced with a choice to either reschedule or contest the denial, I opted to fight. I was furious—furious about my cancer diagnosis, the necessity of a double mastectomy, and the impending revision surgery. I was frustrated that this would mark my tenth procedure in five years. Most of all, I was angry that my health insurance, for which I pay a substantial sum, was rejecting my legitimate claim. I felt utterly let down.

I also worried for other women who might not know their rights and may have received similar denial letters without the capacity to challenge them.

With only 24 hours before my surgery, I knew I had to act fast. The standard appeals process wouldn’t work in my timeframe, so I took a bold approach. I tracked down the names of Blue Shield’s executive team and crafted emails to each one, detailing my situation.

To my surprise, I received prompt responses from five executives expressing concern and offering to escalate my case. I had their attention.

Over the next six hours, I collaborated with Matt S., a compassionate patient liaison who guided me through the process, along with the Blue Shield physician who initially denied the surgery, and my personal doctor who understands my medical history. A peer-to-peer discussion was arranged to clarify the medical necessity of the procedure.

Ultimately, my surgery was approved just 14 hours before I was due to arrive at the hospital. I was relieved yet still seething over the ordeal. I felt for other breast cancer survivors who might have faced similar denials, perhaps accepting them as a grim aspect of their journey.

I sent a follow-up email to the Blue Shield executives who had responded. While some offered standard replies thanking me for my feedback, I wanted to highlight nine key points for Blue Shield of California:

1. My breast cancer diagnosis was not elective; it was life-altering.
2. I should never have to fight for medically necessary procedures and treatments.
3. Federal law protects me, and I should not have to cite it to receive coverage.
4. I worry for others who may lack the energy or knowledge to contest their rights in these situations.
5. In my case, a few photos would have sufficed for approval. A “pending further information” letter could alleviate anxiety instead of an outright denial.
6. Matt S. was a beacon of support during this crisis; he deserves recognition for his empathy. We need more representatives like him in health care.
7. While I appreciate the correction of this “oversight,” it raises questions about whether denying coverage is a cost-saving strategy for Blue Shield.
8. Please learn from this experience and strive to improve your communication and care standards.
9. As a cancer survivor, ongoing testing and procedures will be part of my life. I hope I won’t have to fight for my coverage again—I’m exhausted by the toll it takes.

I hope you never find yourself in a position where you must battle for your health care. However, if you ever feel dissatisfied with your insurance provider’s response or face urgent medical issues, it’s crucial to reach out to the agency overseeing your plan. In California, you can contact the DMHC or the CDI for assistance. For more information on navigating health care, check out resources on intrauterine insemination here.

Blue Shield of California stated, “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.”

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In summary, health care should not be a battlefield. It’s essential for insurance companies to recognize the impact of their decisions on real people’s lives and to ensure that members receive the coverage they are entitled to without unnecessary struggle.