Baby formula bought out-of-network not covered

7 On Your Side with Nina Pineda

Seven On Your Side
April 23, 2013 3:07:01 PM PDT
Anyone dealing with health insurance knows there's a huge price difference if you use an out-of-network provider.

But parents of a newborn were surprised to learn, there was an in-network service they were supposed to order their son's special baby formula from, and since they didn't use it, they were out hundreds.

It's like liquid gold. At $10 a serving, this baby formula is more costly than a cocktail, but its special ingredients are necessary for the Barkolow's newborn, Quinn.

"Right after we fed him he was crying significantly and then we noticed there was blood in his stool," said Colleen Barkalow, Quinn's mother.

Quinn was suffering a severe allergic reaction to even sensitive formula so their pediatrician prescribed the more expensive, allergy-free formula, and said it should be covered by insurance.

"So I contacted them and inquired as far what I would need to do in order to purchase the formula. They just told us to gather the receipts, and submit everything so that's exactly what we did," Barkalow said.

But after buying cases of formula, costing more than $1,300, the family found out they had bought the formula at the wrong place.

"We went to Target, Babies R Us, Wal-Mart, even grocery stores," Barkalow said.

Horizon considers those stores "out of network" and they are not fully covered by Horizon.

Colleen says she was never told the only way the formula would be paid in full is if she used Horizon's in-network delivery service.

"A company called Prompt Care. They had a name and number and they told me if I contacted them then that way they would deliver it right to our doorstep and we wouldn't have to pay out of pocket," Barkalow said.

"So wait a minute, by the calling the 1-800 number, you found after you would have gotten the formula for free and delivered?" 7 On Your Side's Nina Pineda said.

"Yes," Barkalow said.

"So were you told that initially?" Pineda asked.

"No, not at all," Barkalow said.

She appealed to get reimbursed for Quinn's formula, running them $60 per day, but her request got denied.

"We were upset. You know, you rely on them to give you the right information. Nowhere in our books did it say exactly how to go about it or that you had choices, you know, we were doing it in a way that was costing us a whole lot of money," Barkalow said.

So 7 On Your Side reached out to Horizon, pointing out the lack of information Colleen says led to her big bills.

"Because I didn't give up and had Channel 7 backing me up, they couldn't get away," Barkalow said.

After we got involved, her plan administrator, Association Master Trust, reviewed her appeal again and agreed to pay all the out-of-pocket expenses spent on the Similac.

"So how much are you getting back?" Pineda asked.

"$1,300 hundred dollars?" Barkalow said.

"$1,300, dad can you put that to good use?" Pineda asked.

"Absolutely, to diapers," Mr. Barkalow said.

A Horizon representative disputed Colleen's version of the story, saying she wasn't ever given incorrect information regarding her benefits.

Remember, anytime you are spending money on healthcare like medicine, formula, vitamins, whatever, check with your insurance company on what is covered.

There's a big difference with out-of-network doctors and products.

You could wind up spending money you do not have to, but it's up to you to find out!