Issued and entered April 3, 2003 by Frances K. Wallace, Chief Deputy Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On November 10, 2002, XXXXXXXXXXXXX, on behalf of XXXXXXXXXXXXX (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, MCL 550.1901 et seq. After an assessment of the material submitted, the Commissioner accepted the request.

The issue in this matter focuses on Respondent’s contract. 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 December 26, 2002, the Office of Financial and Insurance Services (OFIS) received from Blue Cross Blue Shield of Michigan (BCBSM) the information it used to make its adverse determination in Petitioner’s case.

II
FACTUAL BACKGROUND

Petitioner is a BCBSM member. He seeks full reimbursement for private hospital room costs incurred from XXXXXXXXXXXXXXXXX – XXXXXXXXXXXXXXXX, and from XXXXXXXXXX – XXXXXXXXXXXXXXXX. BCBSM covered all of the services he received in the hospital, but it did not pay the difference between the private room charges and the cost of a semi-private room. The difference in cost was $4,217.75 for Petitioner’s first hospital admission and $135.62 for the second. The total amount in controversy is $4,353.37. Petitioner believes BCBSM should pay that balance, but BCBSM issued a final adverse determination in this matter on November 1, 2002.

III
ISSUE

Did BCBSM properly deny Petitioner coverage for the difference between private hospital room costs and semi-private hospital room costs?

IV
ANALYSIS

PETITIONER’S ARGUMENT

Petitioner believes BCBSM should pay the $4,353.37 balance of the private hospital room charges because there were no semi-private rooms available. He had no choice but to occupy a private room. Petitioner contends BCBSM should pay for the private room charges because they were necessary for him to receive covered health services from a participating provider. Petitioner believes the Commissioner should reverse BCBSM’s final adverse determination in his case.

BCBSM’S ARGUMENT

BCBSM argues Petitioner’s contract covers semi-private hospital room accommodations only, so the difference in cost for a private room is his responsibility. BCBSM asserts that private hospital room accommodations are not a covered inpatient service, so it cannot pay those charges. It therefore argues the Commissioner should uphold its final adverse determination in Petitioner’s case.

COMMISSIONER’S REVIEW

The Commissioner carefully reviewed the arguments and documents presented in this case. The focus of this analysis is whether BCBSM properly denied Petitioner coverage for the difference between private hospital room costs and semi-private hospital room costs. The BCBSM Comprehensive Hospital Care Group Benefit Certificate controls Petitioner’s coverage. The Certificate, in pertinent part, states:

Hospital Services Which are Payable

Payable inpatient services

• Semi-private room

This language clearly informs Certificate holders of the benefits available to them during inpatient hospital admissions. Along with providing benefits for semi-private hospital rooms, the “Payable inpatient services” provision of the Certificate notes a number of other covered services and communicates to BCBSM members exactly what it will pay for as part of an inpatient hospital stay. By including coverage for semi-private rooms and not listing private room benefits as part of its coverage, BCBSM puts Certificate holders on notice that it will not pay for private hospital room accommodations.

The Certificate further clarifies its coverage in “Section 2: The Language of Health Care,” where it defines a semi-private room as a “hospital room with two beds.” This provision removes any ambiguity as to what type of accommodations BCBSM will pay for as part of an inpatient hospital stay. The Commissioner therefore finds that when BCBSM paid the semi-private room rate, it provided Petitioner the benefits under the Certificate. Accordingly, the Commissioner finds BCBSM’s final adverse determination in this matter is valid.

V
ORDER

The Commissioner upholds BCBSM’s November 1, 2002, final adverse determination in Petitioner’s case. BCBSM properly denied Petitioner coverage for the difference between private hospital room costs and semi-private hospital room costs.

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.