A Tennessee Woman Needed a $75K Heart Surgery After Multiple Strokes. Her Insurance Denied the Claim, Saying She Was ‘Low Risk’ for Future Strokes
"Insurance is a scam."
A Nashville woman says she was hospitalized and in need of heart surgery after suffering multiple strokes, and that her insurance company denied coverage for the procedure. According to The Nerd Stash, TikTok user @babszszszsz, known as Babs, shared the denial in a video claiming the insurer argued she was a “low risk” for another stroke.
Babs said her insurance had declined to cover a procedure to close what she called a hole in her heart. According to the Mayo Clinic, that condition is known as a patent foramen ovale, an opening between the heart’s upper chambers that never fully closed after birth. It’s often harmless, but in some people it can lead to ischemic strokes.
Babs said the denial cited “the amount of bubbles on my echo,” a reference to a specific diagnostic test. A bubble study, or agitated saline contrast echocardiogram, involves injecting a saline solution mixed with tiny air bubbles into a vein while an ultrasound tracks the heart. Normally the lungs filter those bubbles out before they reach the heart’s left side; if bubbles show up there anyway, it signals blood is passing through a hole like a PFO instead of following its normal path through the lungs first.
The Surgery Itself Cost Around $75,000
Babs said she had been having stroke events since May. She says she was hospitalized for one on August 15 and suffered another while still admitted. Despite that, she says her insurer would not cover the roughly $75,000 procedure. “Their reason for doing this is my age and the amount of bubbles on my echo,” she said in the video. “And they said I am a low risk for recurrent stroke events.”
She says she was able to raise about half the cost through crowdfunding and private and public donations. The hospital reportedly covered the rest through its financial aid program. Babs identified her insurer in the video as Anthem Blue Cross Blue Shield, and said in a follow-up video that the surgery was successful and that she had been released from the hospital. Anthem has not publicly addressed this case.
Denials like this one aren’t necessarily final. Under the Affordable Care Act, patients in most private health plans have the right to two levels of appeal, according to HealthCare.gov. The first is an internal appeal directly with the insurer, which must be filed within 180 days of the denial and requires the company to explain its reasoning in writing. If the insurer upholds its denial, the patient can request an external review by an independent third party outside the company, a decision the insurer is legally required to accept.
If a plan is employer-sponsored, a separate federal law usually applies on top of that. Most workplace health plans fall under ERISA, which requires insurers to give claimants at least 180 days to appeal and to hand over the entire claim file, including medical records and internal notes the reviewer relied on, within 30 days at no cost. If the plan misses its own procedural deadlines, federal regulations allow the claimant to treat the appeal as automatically exhausted and go straight to court.
Tennessee residents also have a state-level option. The Tennessee Department of Commerce and Insurance accepts consumer complaints against insurance companies directly, and its Consumer Insurance Services division can investigate whether an insurer followed proper claims and appeals procedures under state law.
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