Blue Cross/Blue Shield Won't Cover Bent Diver's Chamber Costs

When Michael Gray suffered neurological decompression sickness while diving in Cozumel in 2004, he was treated at a local chamber several times over four days. The bill came to $8,952, which, according to Mexican law, Gray and his wife, Sherri, were required to pay in full before they left the country.

Dr. Pascual Picolo at Hiberbarica De Cozumel (one of three Cozumel chamber operators) prepared an insurance claim for that amount, which Sherri Gray submitted to the couple’s health insurance carrier, Blue Cross/Blue Shield of Baton Rouge, Louisiana (BCBS). But BCBS only reimbursed the Grays $301.65 of the claim, the maximum Allowable Charge for covered services by an out-ofnetwork provider. That charge was based on the fee BCBS had negotiated with its participating providers.

The Grays took BCBS to court, arguing that their claim “should be paid the same as any other serious emergency treatment in network would be paid.” But a U.S. District Court dismissed their claim, stating, “The record shows that under the terms of the plan, BCBS did pay the same amount on the claim as if it were ‘any other serious emergency treatment in network,’ and that the policy simply did not cover 100 percent of the charges; it only covered 100 percent of the Allowable Charge.” The Grays were out of pocket $8,651.

If the chamber had been an in-network provider, the Grays could not have been charged for the remaining balance. However, because Dr. Picolo had no agreement with BCBS to accept the Allowable Charge in full payment for the services, he was free to charge whatever he saw fit.

If you need a reason to sign up for diving-specific accident insurance offered by the Divers Alert Network and others, this is it. As we reported last year, DAN has had its own problems with one network of hyperbaric chambers that refused to follow DAN’s “usual and customary” rate schedule. That dispute has been settled. DAN’s CEO Dan Orr told Undercurrent that DAN currently covers expenses at any overseas hyperbaric facility; however, that situation may change. DAN is developing an international preferred provider network, including chamber operators, so in time, divers may need to check with DAN when planning a trip to learn which, if any, local chambers are in the DAN network.

Undercurrent wrote in depth about dive medical policies in the January 2005 issue, which is available online.