Issued and entered March 27, 2003 by Frances K. Wallace, Chief Deputy Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On March 5, 2003, XXXXXXXXXXXXXX (Petitioner) filed a request for external review with the Commissioner of the Office of Financial and Insurance Services (Commissioner) under the Patient’s Right to Independent Review Act (PRIRA), MCL 550.1901 et seq. After an assessment of the material submitted, the Commissioner accepted the request.

Petitioner’s case focuses on his contract with Blue Cross Blue Shield of Michigan (BCBSM). There is no medical issue. Therefore, review by an Independent Review Organization (IRO) is not required. The Commissioner reviews contractual issues under MCL 550.1911(7). On March 20, 2003, the Office of Financial and Insurance Services (OFIS) received from BCBSM the information it used to make its adverse determination in Petitioner’s case.

II
FACTUAL BACKGROUND

Petitioner is a (BCBSM) member. He seeks coverage for an inpatient surgical procedure at a hospital that does not participate with BCBSM. The charge for the procedure was $8,344.10.

Petitioner underwent surgical prostatectomy at XXXXXXXX in XXXXXXXXXX, XXXXX(XXXXXXXXXXXXX). He was discharged on XXXXXXXXXXXXXXX. BCBSM paid $210.00, but later claimed that no payment should have been made to Petitioner. It stated it would not to request a refund of this payment.

Petitioner however, believes BCBSM is required to pay hospital costs normally incurred in such surgeries. Petitioner exhausted BCBSM’s internal grievance process, and BCBSM issued a final adverse determination on January 10, 2003.

III
ISSUE

Did BCBSM properly deny Petitioner coverage for a prostatectomy atXXXXXXXXXXX-XXXXXXXXXX?

IV
ANALYSIS

Petitioner’s Argument

Petitioner understands that XXXXXXXXXXXXX does not participate with BCBSM. However, whenever either the Petitioner or his wife had services performed there, BCBSM reimbursed them for amounts BCBSM normally pays for these services. BCBSM however paid only a fraction the amount charged for the hospital for the prostatectomy surgery.

Petitioner claims BCBSM is not fulfilling its duty to provide him with fair medical coverage by refusing to pay more for the $8,344.10 bill involved in this case. Petitioner therefore claims the Commissioner should reverse BCBSM’s final adverse determination.

BCBSM’s Argument

The Petitioner has health coverage under the BCBSM Comprehensive Health Care Co-payment Certificate Series CMM 500. Petitioner’s Certificate provides that coverage at non-participating hospitals is limited to BCBSM’s approved amount for services to treat an accidental injury or for a medical emergency when provided by an accredited non-participating hospital that is located outside of Michigan. Since [Petitioner’s] outpatient services were not the result of an accidental injury, nor were they a medical emergency, payment cannot be approved. Therefore, BCBSM claims the Commissioner should uphold its final adverse determination in this matter.

Commissioner’s Review

The Commissioner carefully reviewed the documents submitted and the arguments of the parties. The focus of this analysis is whether BCBSM properly denied Petitioner coverage for a prostatectomy performed at a non-participating hospital. The Certificate controls Petitioner’s coverage and, in pertinent part, states:

If you go to a nonparticipating hospital, facility or alternative to hospital care provider, you will need to pay most of the charges yourself.

* * *

BCBSM coverage at nonparticipating hospitals is limited to services needed to treat an accidental injury or medical emergency. The following explains your coverage when provided by a non-participating hospital [emphasis added]:

Emergency Services at a Non-Participating Hospital

We will pay our approved amount for emergency services provided by an accredited nonparticipating hospital…

The Certificate also defines “accidental injury” as:

Any physical damage caused by an action, object or substance outside of the body. This includes:

• strains, sprains, cuts and bruises
• allergic reactions cause by an outside force such as bee stings or other insect bites
• extreme frostbite, sunburn, sunstroke
• swallowing poisons
• drug overdosing
• inhaling smoke, carbon monoxide or fumes

The Certificate defines “medical emergency” as:

A condition that occurs suddenly and unexpectedly. This condition could result in serious bodily harm or threaten life unless treated immediately. This is not a condition caused by an accidental injury.

This language establishes that BCBSM limits its benefits for non-participating hospital services to the treatment of accidental injuries and medical emergencies. No other services from non-participating hospitals are eligible for coverage. The Petitioner provided no information that his prostatectomy surgery and related care was treatment for an accidental injury or a medical emergency. XXXXXXXXXXXXXXXXXX does not participate with BCBSM or any other BCBS plan. Therefore, the Commissioner finds the Petitioner’s care at XXXXXXXXXXXXXXXXX is not a covered benefit. Accordingly, the Commissioner finds that BCBSM’s final adverse determination in this matter is valid.

V
ORDER

The Commissioner upholds the BCBSM final adverse determination in this matter. BCBSM properly denied coverage for a prostatectomy performed at a non-participating hospital.

This is a final decision of an administrative agency. Under MCL 550.1915, any person aggrieved by this Order may seek judicial review no later than sixty days from the date of this Order in the Circuit Court for the county where the covered person resides or in the Circuit Court of Ingham County. A copy of the petition for judicial review should be sent to the Commissioner of the Office of Financial and Insurance Services, Health Plans Division, Post Office Box 30220, Lansing, MI 48909-7720.