His mole makes 'medical history' Sorry, we don't cover that diagnosis

March 26, 1993|By Chicago Tribune

It was not necessarily all bad news when CJ Appelson-Smith of Evanston, Ill., learned earlier this week that medical records showed her husband, Jay, was pregnant.

"He deals with pain pretty well," she said. "We want to have a lot of kids someday, too, so this would be a good start."

Then there were the movie rights and tabloid interview fees to consider.

Unfortunately, the diagnosis was a little suspect. Jay Smith, 25, had gone to see Dr. Kenneth Grumet in his Evanston clinic for a routine checkup and to have a mole on his foot looked at last month.

Everything seemed normal. Then came a notice in the mail from Blue Cross and Blue Shield of Illinois saying the $55 insurance claim was denied because "this expense/service is not covered under the condition of your health care plan."

Most people, they shrug, they pay. Who can make sense of health insurance anymore? It covers some of this, all of that, none of the other.

But CJ Appelson-Smith, also 25, is one of those who doesn't shy away from such challenges, and she said she remembered distinctly that Blue Cross had paid for a similar visit a year ago. So she called to inquire.

"The woman told me, 'We won't pay your claim because of the diagnosis.' " Ms. Appelson-Smith said. " 'According to our records, your husband is pregnant, and we don't cover male pregnancies.' "

A sensible stance. You never know what sort of frauds and freaks would try to sign up -- Edwin Bayron, the Filipino male nurse who caused an international stir last year when he claimed to be pregnant comes to mind -- and who wants to be in a risk pool with them?

Jay Smith hadn't been noticeably moody, his wife thought. Wasn't gaining weight. Hadn't been throwing up in the mornings. "I told the woman, 'That's absurd,'" she said. "She told me, "Yes, it was an obvious mistake. That was why they didn't cover it.'"

Dr. Grumet said he is "pretty sure" Jay Smith is not pregnant. His written diagnosis was simply "mole," he said.

An assistant in his office then had to look up the code number for "mole" to file an electronic insurance claim and mistakenly typed in the code for ectopic molar pregnancy.

Hey, it happens. But what was troubling to Dr. Grumet, to CJ Appelson-Smith and to her husband, who really should not be troubled in his first trimester, was how the error moved unimpeded through the system.

Dr. Grumet said he hears of similar though less comical mistakes frequently.

For example, a year and a half ago, he said, his wife gave birth to a premature infant who was hospitalized for four months. "Blue Cross shot the bill back to us and said, 'Sorry, this child is over 25 years old and your policy doesn't cover children over 25.' No one seemed to stop to wonder why a 25-year-old would have needed premature nursery care."

And in Jay Smith's case, no one at the insurance company stopped to call the doctor to ask if this unprecedented male pregnancy was genuine and, if so, did he need an agent.

"We blew it," said Ray Angeli, of Blue Cross and Blue Shield of Illinois. He said the computer, which processes 50,000 to 60,000 claims a day, choked on the unorthodox diagnosis and that the failure to question the doctor and the patient more closely was a clerical error.

The company corrected the error and processed the claim correctly late Wednesday, he said.

"It could have been worse," he said. "We could have paid a claim for male pregnancy."

Or the diagnosis could have glommed on to Jay Smith's medical records forever, showing up when he applied for life insurance or new coverage.

An errant pregnancy diagnosis probably wouldn't be a problem, Dr. Grumet said, but what if the error had instead said "heart attack?"

"The real problem this points up is the dangers in the stockpiling of medical information," Dr. Grumet said. "Everything requires a coded diagnosis that stays with people for years and years."

The Appelson-Smiths, meanwhile, are enjoying the fuss over the putative bun in Jay's oven. Colleagues at WTTW-Ch. 11, where he is a producer, gave him a congratulatory greeting card Wednesday that joked about how big his breasts will soon become.

CJ said her co-workers at the Kohl Children's Museum in Wilmette, Ill., where she is a publicist, are talking about throwing a baby shower.

She reported that her husband already has used his supposed pregnancy as a ploy for sympathy around the house.

"We were bickering about something the other night," she said. "He told me, 'You shouldn't be talking to me like that in the condition I'm in.'"

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