‘Medically necessary’: Conflict between hospital and insurance company leaves Utah family owing over $30K

COALVILLE – Imagine your insurance company denying your claim for surgery after the fact and now you’re on the hook for tens of thousands of dollars. It happened to a Coalville family who says that surgery helped save their son’s life.  

A nasty dirt bike crash nearly killed Rhyley Brundy over a year ago. 

“He said, ‘Mom, call an ambulance!’” his mother, Lacy Brundy, recalled. “’And tell them to hurry!’” 

She said the crash lacerated one of his kidneys and his liver. She credits the quick work of his friends on the scene, paramedics and the heroic efforts of the staff at Primary Children’s Hospital for saving his life — more than once. 

“I watched him pass away once. My husband watched him pass away a few times. It was a big deal,” Brundy said. 

A very big deal that kept Rhyley in the hospital for nearly a month which racked up some daunting medical bills. Brundy had insurance which, except for a few copays, covered most of her son’s stay — but not all.  

Not ‘medically necessary’

The family was left owning $34,119.87, and the reason her insurance company gave Brundy blew her mind. 

“Not medically necessary,” the denial letter from her insurance read. “Your plan does not cover that kind of care.”  

That “kind of care” was her son, still in the intensive care unit, on doctor’s orders. They certainly thought it was medically necessary and wrote as much in an appeal letter to the insurance company on Brundy and Rhyley’s behalf. 

For more than a year, Brundy says she and her insurance company have battled over that bill with them vacillating between agreeing to pay and then saying they will not. 

“I don’t understand why they’ve covered everything else but these two days,” she said. 

But the bill remained unpaid, and the patience of the hospital’s bill collectors had run out. 

“Now they’ve sent me to collections, and I just don’t know what to do,” Brundy said. 

Not wanting to go bankrupt over a bill that she feels insurance should have covered, Lacy decided it was time to contact the KSL Investigators.  

An insurance tug-of-war 

We reached out to both the insurance company, Anthem Blue Cross Blue Shield, and Primary Children’s Hospital. 

The two companies pointed the finger at each other. Over the phone, Anthem’s spokesperson told us Primary Children’s “failed to submit documentation that was requested” in a timely manner. 

Not true, said the hospital. Primary Children’s told us they sent everything “to the patient’s insurance six days after the patient left the hospital.” They say they “spent more than a year working with the insurance company and appealing on behalf of the patient.” 

“Anytime I think about it, I want to cry,” Brundy said. “It’s just not fair.” 

In the end, Anthem refused to budge on increasing its payout. Primary Children’s Hospital, though, pulled off some heroics for Lacy’s family. They provided some financial aid and adjustments which essentially wiped out the bill. In fact, she wound up getting about $80 back.  

What to do? 

These sorts of tugs-of-war between hospitals and insurance companies are common. Should you find yourself in one, you can file a complaint with the Utah Insurance Department, or the insurance department of whatever state the insurance company is based in.  

And don’t wait too long. After a year, it can be much harder to force an insurance company to pay, even if it is determined they’re in the wrong.