Heartless: How One Abnormal Pap Smear Lost a Woman Access to Gynecological Care

“It just got scarier and scarier,” Anna Haas said, describing a recent visit to the doctor. But instead of a medical procedure, Haas was remembering her experience with her health insurance company.

During a routine exam at her gynecologist in which she had her annual pap smear, the 26-year-old singer-songwriter's doctor found a bump with precancerous cells. After her pap smear tested abnormal, her doctor recommended she have a colposcopy to examine the cervix and remove the suspicious bump that could potentially develop into cervical cancer.

Following the procedure, Haas switched from her parents’ insurance plan with Blue Cross Blue Shield to her own individual plan. No time lapsed between the two plans, and she was never without insurance. When filling out the online enrollment for her new plan, Haas was asked if she had ever undergone a non-routine procedure over the past year, and she listed the colposcopy.

“I didn’t think anything of it,” Haas said. “I didn’t think for a second this would affect my coverage. I didn’t see this polyp as a pre-existing condition. I saw it as proof I was a responsible adult that was taking charge of my health and dealing with a small health issue so it didn’t grow into something worse.”

Haas received a letter from Blue Cross Blue Shield stating that she was approved for the plan she had requested, but that she was denied coverage for many aspects of gynecological care related to an abnormal pap smear. This would include everything from women’s preventative health maintenance such as future pap smears, to coverage for cervical cancer, should that develop.

“I was really scared,” Haas said. “I had always heard about friends who didn’t have health insurance, horror stories of what they had to go through with their illnesses… I’m somebody who has never really been sick, never had a major surgery. This is the most minor thing I could possibly have, and I took preventative measures to get it removed. And I was still denied coverage for all gynecological care.”

She turned to her father, David Haas, an infectious diseases physician in Nashville, for help. She said, “The next year consisted of [my father] fighting against Blue Cross Blue Shield using all manner of persuasion to get them to cover me in full, for perhaps the most important type of health care a woman should be entitled to, that I had been denied.”

“My first thought was there was clearly a misunderstanding,” David Haas said. (He made it clear he was speaking as an individual and a father, not as a faculty member of a major academic medical center.) His first attempt at resolving the problem consisted of a one-paragraph letter to BCBS requesting that his daughter be covered. “I made it clear that she had continuous coverage with BCBS since she was born 26 years ago, so how could this be a pre-existing condition?”

“I figured it was a misunderstanding—a clerical thing—and it would not be an issue,” he continued. “Then we got a response from BCBS underwriters who review requests like these, and it said they would stand by their decision and she would not be covered for anything related to the abnormal pap smear.”

Following David Haas' first letter, the consistent denials from Blue Cross Blue Shield served as an eye-opener for Anna, especially the impersonal aspects of the business. “There’s no sensitive person giving any real sympathetic or heartfelt consideration,” she said. “It’s obviously all numbers and paper. Our healthcare system is so disconnected and cold. It’s a system that should be helping us take care of our bodies and minds. For it to be so disconnected and unemotional is inhumane and ironic.”

The next communication between David and Blue Cross Blue Shield said that if Anna received three regular pap smears in a row, six months apart, they would consider covering her.

“The more and more this blew up, I couldn’t believe that something so small—this tiny little polyp—could turn into being denied such an essential part of women’s health coverage,” Anna added.

David sent a longer letter detailing rationale as to why Anna should be covered, and Blue Cross Blue Shield responded by saying he should submit a formal grievance to BCBS Tennessee. David did so, emphasizing in his letter that he works as an infectious disease specialist.

“I made the point that I work at an educational institution and I have the opportunity to host people coming to our grand rounds conferences,” he said. “We might wish to invite people from Blue Cross Blue Shield to come and discuss their policy more widely—perhaps a panel discussion involving several individuals: my daughter; me as a parent and infectious disease specialist; and an employee from Blue Cross Blue Shield. I asked them to consider who would be a representative.”

David, who also emphasized that his family had been loyal customers of Blue Cross Blue Shield for more than 20 years, included in his letter copies of various documents as well as Anna’s pathology report showing the bump was a mild dysplasia, the letter showing that she was being denied coverage and information on his infectious disease background.

He received a response saying that Anna would still be denied coverage for anything related to the abnormal pap smear. He sent another letter, including the development that Anna had a repeat pap smear in December 2011, which was normal.

In a letter written in March 2012, he stated,

“Again, if it is the policy of BC/BS to refuse coverage for an abnormal Pap smear found during such preventive visits in someone approaching their 26th birthday, and will be transitioning to a new BC/BS policy, I request that you advise how many years in advance of their 26th birthdays young women covered under their parents’ BC/BS policies should stop preventive care visits, so as to avoid having any abnormal finding while they are under the coverage of BC/BS of Tennessee.

“Again, it seems to me that this posture is being taken by BC/BS of Tennessee to avoid future coverage of reproductive health for my daughter, based on a ‘non-diagnosis’ of a minimally abnormal Pap smear (CIN I, generally a consequence of human papilloma virus). The likelihood of such an abnormality progressing to disease is very small, especially with appropriate gynecologic care, but your decision to not cover my daughter for future care discourages her from obtaining such care and puts her at increased risk for disease. This seems highly discriminatory against young women of reproductive age.”

David included in his letter his plans for a panel discussion at 2012 Vanderbilt Infectious Diseases Grand Rounds involving three individuals at the front of the room: 1) himself (for the parent/infectious diseases specialist perspective); 2) Anna (a young woman for the consumer/young sexually active woman perspective); and 3) Vicky Gregg, CEO of BC/BS of Tennessee (or another BC/BS of Tennessee employee to represent Gregg.

The planned title of the panel discussion was, “Understanding Insurance Policies on Pre-Existing Conditions and Women’s Health." The subtitle was going to be, “What every parent should know.” He planned on inviting reporters, congressmen and senators, with the goal of using an instructive case to openly discuss the rationale for denying coverage to a young woman with a pre-existing condition that occurred through her 25th year with Blue Cross Blue Shield. The second topic was the relationship between minimally abnormal pap smears and infectious disease, and the third was children covered through their parents’ policies before transitioning to their own.

Following this communication, David received another letter saying that Anna would still be denied coverage. Two days later, he received another letter that said the Benefit Exclusion Rider for Abnormal Pap Smears would be lifted, effective April 1, 2012.

“I could only speculate on why this decision was changed,” David said. “I found it very curious. I said I sent a letter to both the underwriter and the CEO. I received a denial from the underwriter, and then a couple of days later, they said they reconsidered.”

Blue Cross Blue Shield did not respond to requests for an interview for this article.

“I kept thinking of the magnitude of the implications of this in regard to the rest of the country,” Anna said of the experience. “If this is happening to me, someone who takes pride in my health, who grew up in a middle-class family with consistent health insurance, then I can’t even imagine what the majority of Americans are dealing with.”

David shared Anna’s distress, saying, “I entered into the process just assuming the right thing would be done, that it was absolutely unimaginable that someone would avoid having a pap smear done, having insurance, thinking they would lose insurance because they got a pap smear. That was actually a common scenario.

“Going into this, I was actually a little bit concerned about being too forceful,” he added. “We were dependent on insurance companies to help us. I didn’t want to get into an adversarial relationship with the insurance company. I came to the realization that we were already inherently in an adverse relationship with the insurance company. From the moment they denied coverage for the pap smear, the relationship between my daughter and the insurance company’s driving force had nothing with doing what was best for my daughter or doing the right thing.”

David went on to say, “The insurance company found a way to deny something for my daughter that I think the overwhelming majority of people would not be able to fight against. This took a lot of consistent time and effort over multiple letters to client coverage. It also took quite a bit of knowledge on my part to understand what the meaning was of the abnormal pap smear, and, if properly handled, it should not have any detrimental effect on a person’s life.

“But to be denied coverage for it may lead to detrimental outcomes in a person’s life because they’re not getting the treatment they need. They could develop cervical cancer and require care after that. When you think of the cost of care for serious conditions and what that could mean to an individual or family, it can be devastating if you don’t have insurance,” he continued. “It can be many hundreds of thousands of dollars to treat a condition that could be preventable through care.”

“I’m lucky that I have a father who cares this much and is this influential,” Anna said. “Most people do not have someone who’s going to fight that hard for them and with the knowledge that he has. If this is happening to me, then most people with more detrimental health concerns are fucked.”

When discussing his experience, which he described as a “shock,” David Haas said, “I talked to a couple of people who said this is exactly what you should expect, and you can’t do anything about it. So I don’t know how broad an issue this has been. I don’t know if it’s unique to BCBS TN, or whether this is typical of other insurance companies. Maybe my experience was unique and this has not happened to anyone else… Before I had this personal experience, the discussions about health insurance had been kind of abstract. We’ve always had health insurance. We’ve paid for health insurance. It never occurred to me that it would be possible for my daughter, the daughter of a physician, to not be able to heave health insurance for one of the most important aspects of a woman’s life… If a person doesn’t have health insurance, that person either has to be in denial about what could happen, or worry themselves to death and hope to not get sick.”

Anna Haas shares her father’s opinion on the importance of health insurance. “Not only should women’s reproductive health not be denied, I think it’s the most important part of health care. A society that doesn’t respect the right of women to keep their bodies healthy is not a healthy society. Reproduction is in everyone’s best interest. If you’re talking purely evolutionary, it’s all about reproduction. So why do health insurance companies make it hard for women to control their family planning? Why do they make it so hard to make responsible choices in that regard, whether it’s having a baby or not having a baby? Or making sure you don’t have cervical cancer so you can have a baby? Or making sure you don’t have STDs or HIV so you can have a healthy sexual relationship?”

“I would hope she [Vicky Gregg] understands the irony of being a woman president of BCBS Tennessee and denying young sexually active young women the chance to have gynecological care,” Anna said.


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