Connecting People to Power


This is the model complaint text provided on lobblyline.com on January 2003.

COMPLAINT AGAINST CAREFIRST under the Deceptive Marketing Practices Act, DC Statute § 31-3407, and any other relevant consumer protection laws of D.C. , the U.S. and any other relevant jurisdictions.


My family has a health insurance policy with CareFirst and like approximately 8,000 families in the Washington area, we use Children's Hospital's first rate medical staff and facilities for our family's medical care. On January 31, 2002 CareFirst is scheduled to end coverage of care at Children's for CareFirst subscribers.

I am writing to file a two-pronged complaint against CareFirst Blue Cross Blue Shield charging them with violation of the Deceptive Marketing Practices Act for (1) deceptive marketing and (2) improper rates. CareFirst BlueCross used Children’s as a carrot to lure me into its policy, keep me there, then caused me to rely upon this policy to my detriment, turning down other opportunities for insurance coverage at Children’s, only to then eliminate Children’s from the network to cut costs, leaving me with no comparable health care provider. Therefore, I seek the remedy that allows me to continue to use Children's physician's, facilities and services at the same level as I have done under the policy up to now, and at the same or similar in-network rates as before, and I do not want to be responsible for large advance payments under a CareFirst reimbursement scheme for payments due to Children’s.


My child needs medical care for a particular condition. Children’s provides the best medical care for my child. I will accept nothing less than the best for my child because anything less than the best compromises the well being of my child. CareFirst would have me believe that it is acceptable for me and are requiring me to seek out medical care for my child from other providers and at adult hospitals. I can not obtain the same quality care or facilities from other providers outside Children’s. I need to continue to use the doctors and facilities at Children’s Hospital.


One of the most significant reasons that I obtained a CareFirst BlueCross BlueShield policy is that I needed access to Children's for the medical care of my child.
CareFirst failed to give me adequate and fair notice of its decision to stop offering coverage for use of Children’s and its services when CareFirst had a reasonable expectation that it would discontinue participation in Children’s insurance network as far back as 2001. I contend that it was then that CareFirst made its plan to terminate the Children’s contract since it wanted to improve its desirability for the purposes of converting to a for-profit. CareFirst should have notified me that its application to convert and merge could affect the providers in its network.

CareFirst is reported to have not directly, personally or individually informed people that its coverage would end at Children’s – even to this day. It is widely believed that the way that most policyholders found out was either (1) by word of mouth or (2) Children’s hospital written notifications (some dated November 4). Many policy holders report that CAREFIRST MARKETED COVERAGE AT CHILDREN’S WITHIN A FEW SHORT WEEKS OF ITS CONTRACT EXPIRATION AT CHILDREN’S.

CareFirst may claim that it had no intention to end its contract with Children’s in 2001 while preparing its application for conversion. However, at the very least, CareFirst had a reasonable expectation that it would terminate coverage at Children’s by the end of summer 2002 and early fall of 2002 when negotiations with Children’s were looking grim. Yet CareFirst told me nothing.

The records of negotiation dates and memoranda would likely support this contention. Even as negotiations clearly deteriorated and the December 31st contract expiration date approached – through most of November – many if not most policyholders likely had heard nothing from CareFirst about their intention to leave Children’s on December 31.

Examine closely the dates when negotiations plummeted as against the expiration date of the contract between CareFirst and Children’s -- December 31st, 2002. If the contract expired on December 31st good faith action by CareFirst would have had them declare September 31st the deadline for ending negotiation talks for good in order to give families a fair and reasonable 3 months (6 months is the ideal) of notice of the termination. So why didn't they tell us? It's simple - that would have caused a mass departure of members from the CareFirst plan at the first opportunity - the open enrollment season that fell in October for some and December for others.

Susan Frazier-Harris of Alexandria Virginia is known to have received her notification of termination on November 20, 2002. This is the first date that I know of in which anyone received notification of termination from CareFirst. It strains credulity to believe that up to the eleventh hour, November 20, 2002, CareFirst really believed that it would reach a deal with Children’s Hospital. CareFirst knew that it would not and continued to represent otherwise to prospective CareFirst enrollees and me, a current policy holder that it might make a deal.


Moreover, two open enrollment seasons – one for local Fairfax County employees and one for federal government employees - opened and closed during the protracted negotiations between CareFirst and Children’s, and CareFirst made no affirmative good faith effort to inform its members using Children’s personally and individually of its scheduled contract termination with Children’s. From October 1 – October 31, Fairfax County had advertised in its Employee Handbook that there was ‘no change’ to the CareFirst insurance plan. The federal government’s open season occurred from December 1st – December 31st. Some reports, including in the Washington Post, indicate that many federal employees failed to receive clear and complete notice of the change in coverage.

By September 2002, prior to the open enrollment season, we should have been told by CareFirst that talks had soured and were NOT likely to resolve with coverage at Children’s in September of 2002. That way, we could have exercised the option to obtain a policy with another insurance carrier. Instead, CareFirst decided to deceive me and its other policyholders.


On November 4, Children’s informed many parents that CareFirst would no longer insure their child’s care at Children’s. By that time, the Fairfax County open enrollment season had just ended as of October 31. THIS WAS BLATANT AND ILLEGAL DECEPTION BY CAREFIRST. The Fairfax County Board of Supervisors, in their November 18, 2002 ‘Board Matter,’ the record of their meeting, indicates that they had been unaware of the scheduled contract termination. Thus, they, too, had been deceived by CareFirst. Susan Harris, of Alexandria Virginia, indicates and an allusion is in the record to this effect, that she was left the task of bringing the contract termination issue to the attention of Fairfax County officials. It was really CareFirst's job to do this.


I was duped by CareFirst because until recently they have been marketing their insurance plan as one that offers access to Children’s Hospital. At the time that I enrolled I was informed through CareFirst material, among other information, that I could use Children’s. Then, in the early Fall 2002, I became aware that CareFirst would no longer cover visits or services at Children’s Hospital. They duped me instead.

CareFirst behaved in illegal and deceptive behavior when it failed to tell me that it was in the midst of unsuccessful negotiations that would likely lead to no coverage of policyholders using Children’s. CareFirst did not tell me. They lied by omission. They broke the law.

No matter when policyholders enrolled in CareFirst, I believe that CareFirst has been misrepresenting the services and doctors that it will insure by omitting mention of its contract dispute with Children’s. I have heard reports that some policyholders enrolled in CareFirst within the past couple of months and have not been told about the removal of Children’s from the CareFirst network. This is the clearest sign of deception since it is reasonable for CareFirst to have had an expectation of leaving Children’s.

Some of us policyholders have joined in the past year or so, since the for-profit conversion process ensued. I contend that CareFirst knew it would drop Children’s in the belief that it was too expensive for its for-profit aspirations. Finally, there are those policyholders who have been insured with CareFirst for better than 20 years. However, although these long-time policyholders enrolled well before CareFirst established its intention to remove Children’s from their network because of the for-profit merger or because of difficult contract renegotiation, long-time policy holders too were deceived. What the majority of CareFirst insured members have in common is the fact that they remained in the network of CareFirst through at least one open enrollment season in late 2002, when contract negotiations had drastically deteriorated, when CareFirst were legally obligated to inform its members that it would no longer cover their care at Children’s. CareFirst did not. CareFirst deceived them as well.


Had I known CareFirst was ending coverage at Children’s I could have better safeguarded my child’s health. Any day, my child may suffer for not having access to Children's. My child could become critically ill and experience grave medical consequences without access to Children’s. I cannot afford to continue to use Children’s without CareFirst coverage – either out of network or out-of-pocket. I have no other options. What of parents with doctors’ appointments after January 31st? They are having almost zero success with getting CareFirst coverage at Children’s as a ‘medical necessity’. We can not afford to purchase an individual policy with an insurance carrier that does cover Children’s. Now that we have begun care at Children’s. CareFirst are leaving us in the lurch. What kind of care will my child receive now?


CareFirst vastly reduces the quality and range of medical care it can cover by leaving Children's. Thus, the rates it is charging me based upon these services are improper and in violation of the law. Terminating the contract with Children's makes the rates improper.


I charge that CareFirst’s actions were taken intentionally to get my business and to get my employer’s business. They deceptively marketed the policy to me and my family. CareFirst is also violating the law against improper rates.


I seek any and all remedies that are allowable under the laws of the District of Columbia and any other relevant jurisdictions.

First, I want to be restored to coverage at Children's Hospital for as long as I am insured by CareFirst.

Second, in the alternative, I want to keep using Children's if CareFirst does eventually drop Children's from its network of covered providers. I want to continue to pay affordable fees at the in-network rates that I was originally promised that I would receive. I want an arrangement that allows Children's Hospital to bill CareFirst so that I do not have to advance payments and then pursue reimbursement at my own risk.



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