Issued and entered June 11, 2003 by Linda A. Watters, Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On May 16, 2003, XXXXXXXXXXXXXXX (Petitioner), filed a request for external review with the Commissioner of Financial and Insurance Services (Commissioner) under the Patient’s Right to Independent Review Act (PRIRA) MCL 550.1901 et seq. After a review of the material submitted, the Commissioner accepted the request on May 23, 2003.

The issue involved in the adverse determination is contractual. The Commissioner reviews contractual issues pursuant to MCL 550.1911(7). As a result, review by an independent review organization is not required. The Commissioner notified Blue Cross and Blue Shield of Michigan (BCBSM) of Petitioner’s filing and requested the information it used in making its adverse determination.

II
FACTUAL BACKGROUND

On XXXXXXXXXXXXXX, the Petitioner underwent a CAT Scan at XXXXXXXXXXXXXXXX. The charge for the service was $1,116.00 and BCBSM approved it maximum payment of $249.39. Since the Provider participates with BCBSM it agreed to accept the approved amount as payment in full. However, because the Petitioner had not met his annual deductible of $275.00, the approved amount was applied to his deductible.

Petitioner believes BCBSM misled him to believe that the payment for the last part of XXXX can be applied to his XXXX deductible.

III
ISSUE

Is Blue Cross and Blue Shield of Michigan (BCBSM) required to apply the $249.39 approved for the Petitioner’s CAT Scan to his 2003 deductible?

IV
ANALYSIS

Petitioner’s Argument

Before the Petitioner had his CAT Scan (on XXXXXXXXXXXXXXXXX) he called BCBSM and inquired about a “carryover” if medical treatment was done late in the year. He knew he had not met his deductible for the year. If he could not carry over the payment to apply to the XXXX deductible he would wait and have to CAT Scan in XXXX. The BCBSM representative told him he did have a carryover if medical treatment was done late in the year. Based on this information he went ahead with the procedure on XXXXXXXXXXXXXXXXX. What BCBSM failed to inform him was that the carryover only applied to major medical charges and did not apply to his CAT Scan.

The Petitioner argues that BCBSM’s misinformation required him to pay an addition $249.39 in deductibles. He believes that BCBSM should apply this amount to his XXXX deductible. If this is done, BCBSM is required to pay the Petitioner an additional $249.39.

BCBSM’s Argument

Petitioner has health coverage under BCBSM’s Comprehensive Hospital Care Group Benefit Certificate, as amended by Rider DRI Deductible Requirement and the Master Medical Supplemental Benefit Certificate Catastrophic Coverage Plan Option 1.

Under the contract language the Petitioner is required to pay each calendar year a $275 deductible. The only deductible carryover provision is found in his Master Medical Certificate, and that carryover provision applies only to the “additional” benefits that are contained in that Certificate. Unfortunately for the Petitioner, CAT Scans are not an additional benefit covered by the Master Medical Certificate; rather, they are a benefit of his basic coverage. As a result there is no deductible carryover for the CAT Scan.

BCBSM argues that it can find no record in its phone logs of a conversation with the Petitioner shortly before the XXXXXXXXXXXXXXXXX, CAT Scan. The only phone call listed in XXXX was made on XXXXXXXXXXXXXX. BCBSM doubts the Petitioner called about he CAT Scan four months prior to the service being provided. Therefore, BCBSM argues it could not have misled him to believe his services would be carried over to the XXXX deductible.

BCBSM claims that under the Certificate it has properly applied the $249.39 approved for the CAT Scan to the XXXX deductible.

Commissioner’s Review

The Petitioner does not dispute that his BCBSM Certificate and riders require him to pay a $275 annual deductible. He also does not challenge that the carryover provision in his Master Medical Rider does not apply to his CAT Scan. His sole argument is that in a phone conversation with BCBSM misled him to believe the $249.39 amount approved for his CAT Scan would be applied to his XXXX deductible.

Petitioner’s argument is grounded on facts pertaining to a phone conversation. Such claims require production of meticulous records and specific evidence of any representation. The case file contains only Petitioner’s general statement about a BCBSM representation. The lack of detailed evidence militates against Petitioner’s claim.

Indeed, it is very difficult for the Commissioner to know what is said in phone conversations. Many times the parties misunderstand what is being said. It is also possible a BCBSM representative told the Petitioner he had a carryover provision in the Certificate, a true statement. However, it is unclear whether the BCBSM representative understood the service to be provided was a CAT Scan. In light of the scant evidence presented, the Commissioner finds BCBSM did not mislead the Petitioner to believe $249.39 CAT Scan approved amount would be applied to the XXXX deductible.

V
ORDER

The Commissioner upholds BCBSM’s May 8, 2003, final adverse determination. BCBSM is not required to pay an additional amount for Petitioner’s XXXXXXXXXXXXXXXXX, CAT Scan.

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.