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08 September 2008

Tales of Insurance Horror A good friend's mom has breast cancer. Her insurance company is now denying payment for the mastectomy... after the fact.[More:]
She was told it would be covered since, well, it was that or death. Now that the surgery's over and she's recovering (with good odds so far!) they're refusing to pay.

Anyone deal with something like this before? What kind of options do they have?
I feel so awful for them, I can't even imagine what kind of hell this is after all they've already gone through. Appropriately enough, my friend found this out the same day the (very same) insurance company told him that, although they covered his sleep clinic visit since two hours sleep a night is a problem, they will not cover any of the treatments or prescriptions the clinic recommends.
I think the number-one thing is, keep fighting.

Appeal in whatever means the insurance allows. Talk to the doctor's office staff and see if they can send further documentation -- it's possible the info they sent had an outdated (or miscoded) diagnosis, or that they can show some sort of "This is the standard of care" documentation. Or they may have personal experience with the provider and know what info needs to be sent along, or who to talk to to get a better response.

If the insurance continues to refuse to pay, I think she can probably let the hospital or doctors know that and they may be able to work out a payment plan or deal with her.

Insurance in this country sucks. :-(
posted by occhiblu 08 September | 01:08
yes, keep fighting. And once you've given up hope on the insurance, have her fight some more. And after that, be insistent with the hospital. And if that doesn't work, ask for a payment plan. $20 for the rest of her life, per month.

*sorry that I know this, sorry that your friend is going through this. Agreeing with occhiblu, the state of health care in this country sucks, more than anything, and must change.*
posted by Sil 08 September | 02:08
Jesus... I can hardly imagine how difficult that would be. The fact that this can happen (and surely happens every day) is an outrage.

Taking it to the media might shame the company into honouring their agreement. It would be a tiring, invasive process, but desperate times call for desperate measures.
posted by loiseau 08 September | 02:08
Taking it to the media might shame the company into honouring their agreement.

Sadly I don't think the media would give a shit - this is SOP and happens everywhere in the US every day. What a sick and twisted system.

My sympathies kellydamnit.
posted by Meatbomb 08 September | 06:26
Sadly I don't think the media would give a shit - this is SOP and happens everywhere in the US every day. What a sick and twisted system.

Shit, seriously? That is sick and twisted. I dunno. I truly believe health care is a fundamental right of all people, not just the wealthy. The whole system just goes against my values completely.

I've been freaking out reading people's perspectives on Palin lately, realizing how many people really love her. One really scary thing I read last night was a woman saying that she opposed Obama because she didn't believe that she should be "forced to have healthcare." It is sad when the good of ALL people is seen as an infringement on one's personal religion of "freedom".

I wish I didn't think this election was so important for y'all and for the whole world because if I didn't I could just stop reading things and growing more and more depressed.

I dunno, Kelly, I feel like reading about your friend's mom's story would have to mobilize people to create change in your country... are you guys sure it wouldn't create an outrage? Because it sure as hell should.
posted by loiseau 08 September | 07:41
No, loiseau, it wouldn't create an outrage because it happens every single day to many, many people. It wouldn't create an outrage any more than the extra $9,000 I owed for my son's surgery after Blue Cross had paid what they would created an outrage. It wouldn't create an outrage any more than the $83,000 - yes, that's EIGHTY THREE THOUSAND DOLLARS - that my aunt now owes in hospital bills over and above what Medicare will pay for her stroke. The United States: the only "first world" country on the planet where it's de rigeur to host a bake sale and benefit concert to try to pay your medical expenses, right before you lose your home and go bankrupt.
posted by mygothlaundry 08 September | 08:12
That depresses me. Just because it happens every day doesn't mean that each case isn't an outrage. (IMO)

I mean, the company committed and then went back on their word. Above and beyond the inequality of the system, there has to be some leverage there? Does she have anything on paper? Did they give her grounds for the reversal?
posted by loiseau 08 September | 08:31
Fight it. Keep fighting. Their first answer is always NO. So is their second answer.

But, keep fighting. They win by wearing you down and denying every claim. I know this from our experience.

They denied every one of our first claims by trying to say it was a "pre-existing condition", which it was not. But, they still put us through the wringer on it when all we should have been focusing on was his getting proper treatment.

We fought them and partially won some of our battles except they raised my hubby's rates to $1,100 per month for his heath insurance. We cashed out all of our retirement fund and lived on credit cards to pay for the stuff that was-out-of-network or not covered. I'll be paying for it forever.

It's a great system until you have something....

But, keep fighting because you can get them to reverse decisions. Call the doctor's office and speak to whoever works on filing the insurance stuff. They can provide documentation saying that this was pre-approved (hopefully) - sometimes the doc's office can be quite helpful...
posted by mightshould 08 September | 09:27
That's what I thought, too. But then, I filed bankruptcy at 24 for almost 40,000 in medical bills. And something like three quarters of all people who file do so for medical bills.
When I had my car accident the bills, thankfully paid by my auto insurance, topped out over one million dollars. (ten years later I think it's at about 1 and a quarter with the followups and so on)
I guess she is appealing through the company, and worst case they plan to lawyer up and hit them hard.
posted by kellydamnit 08 September | 09:30
Holy crap.

Kelly, are you USian? Every state has an insurance regulation department, as well as a consumer affairs department. Call your state attorney generals office, contact both depts., and get them to help.

posted by theora55 08 September | 09:38
I'll repeat what others have said.

Kelly, I have had payment denied when the doctor's office didn't code my diagnosis correctly. I have also had payment denied when I broke my ankle and the office person wrote the wrong year by mistake. Insurance refused to pay because of this mistake. Mistakes like this happen frequently. With my othro bills I had to appeal because of the office error. I literally just had a baby and paid cash because I didn't want to go through the hassle. This is a tactic. They make things difficult on purpose.

Also, as you and your friends are probably ware, some insurances require you to jump through hoops and pre-register for surgery and/or go through the proper channels for referrals. Hopefully it is something she can appeal or straighten out with proper documentation if everything wasn't done to exact requirements.

loiseau, I'm not defending health care in our country, but it's not all terrible. First, we generally give exceptional medical care in this country. It's true, health insurance is a huge racket in this country. Some providors are better than others. I have a Blue Cross Blue Shield PPO. It's a 70/30 plan. We choose 70/30 because our premiums are affordable. My husband owns his own business and I work very part time. If I wanted better coverage I could work full-time or we could pay more. Not everybody has the luxury of having good coverage. I do. I could have it if I wanted but I don't want to work so much. My husband and I choose not to carry it and that's the chance we take. The year I had surgery and my husband had a minor health problem come up, we paid 19,000 bucks out of pocket. We could afford to pay but it would have been nice not to. It's a gamble we take.
posted by LoriFLA 08 September | 11:32
I will nth the "keep fighting it" sentiment. If they ever told you that it would be covered, and you can prove it (saved email? letters? recordings?), then you should be able to wrassle it out of them.

I will also toss in the "lawyer up" option. I don't know about where you live, but around here there are several attorneys that specialize in health insurance cases that advertise all the time for free consultations. The idea is that you go talk to them for free, and they decide whether they think they can get the money out of the insurance company, plus fees for themselves. If they decide it's a good bet, then they do the litigation for you (usually settles) and no money comes out of your pocket. Caveat Emptor, of course, but it may be worth a shot in your case.
posted by Lafe 08 September | 12:17
If it wasn't a deal where she paid the doctor and hospital out of pocket and then the insurance was supposed to reimburse her, then she's got additional leverage in that the doctor and hospital will get screwed out of the insurance payment, too (because they're likely to accept a lower payment from her if it ends up being completely out of her pocket). So she should really look at the hospital billing staff and her doctor's billing staff as potential allies.
posted by occhiblu 08 September | 14:24
Yes, do let the doctor's office know-whoever handles their insurance there will help-I had this happen to me with the birth of my last child-the doc's office took care of it.

If that doesn't do it, go up the chain here as others recommend-don't let them get away with it!
posted by bunnyfire 08 September | 15:04
The year I had surgery and my husband had a minor health problem come up, we paid 19,000 bucks out of pocket. We could afford to pay but it would have been nice not to.
In a modern, civilised, wealthy country, why should you have to pay for basic health care at all? Yeah, yeah, taxes, I know, but why should you have to pay directly for basic care like that? This continues to baffle me, even though it's none of my business.
posted by dg 08 September | 15:46
Kelly - send your story to Consumerist. Lots of their items are picked up by Digg, etc. and shared widely across the web, leading companies to change their minds. Naming and shaming really does still work, as insurers don't want their clients to realize just how biased the system is against them.
posted by Susurration 08 September | 18:38
I apologize for my dollar figure above. I am thinking of another year and another surgery and hospital stay and we still didn't pay quite that much.

The year I'm speaking of with my current insurance, I only paid 4000 out of pocket. Which is still a lot, but no where near 19. I don't know where my head was.

In a modern, civilized, wealthy country, why should you have to pay for basic health care at all? Yeah, yeah, taxes, I know, but why should you have to pay directly for basic care like that?

I'll put it in very simple and crude terms. The individual pays for health care because it's incentive to get off your ass. Americans are generally adverse for paying for someone else. We loathe deadbeats. We fear tax increases. Personal responsibility and all that. I'm not saying I agree, or that we don't have serious problems, but this is why.
posted by LoriFLA 08 September | 19:07
Actually, you know, if we had a one payer system like a civilized country, we'd pay the same OR LESS in taxes as we are now if you factor what most insured Americans are already paying right out of their paychecks. I pay almost $300 a month out of my check towards my health insurance. Given my (meager, admittedly) income, if that was coming out as tax, it would almost certainly be less AND I wouldn't still be paying the extra $700 that Blue Cross refused to pay for the CT scan I had last October. And my kid would be insured. So, newsflash, that argument doesn't work out at all.
posted by mygothlaundry 08 September | 20:01
I agree with you completely, mgl and can relate to your experiences because I have experienced the same things. I have had some doctors that would accept BCBS pre-assigned amount for services. I have had some doctors that would not, and I had to pay the difference.

I hope I didn't come across as agreeing with the argument. It is a poor argument but a common mentality.
posted by LoriFLA 08 September | 20:19
Thanks for the explanation, LoriFLA. What you said makes prefect sense. But. When it comes to life essentials like basic health care, that argument just doesn't hold water, if only because it punishes those who have the least resources by forcing them to either forgo basic care or pay exorbitant fees just for the peace of mind that they will only have to pay a small fortune when they really need care. God know the system in place here has its problems but, in my experience, people who really need the care get it. They may not get a private room and their choice of doctor, but they generally get the care they need. By exempting low income earners (something like <$30k from memory) from having to contribute and making those on higher incomes (something like >$100k from memory) pay a slightly higher rate, there is at least some proportionality in the system.

Here's a personal example and maybe why I am something of a fan of Medicare - my son was born with a Complex Syndactyly of one hand. He has so far had three operations (and will need several more as he grows), which have been conducted by a doctor renowned as the best hand surgeon in the country, along with the consultations and tests etc that go along with it. He has also had occupational therapy at one of the best hospitals in the state following each surgery. The whole thing has cost us only some time off work to take him to clinics and surgery. If we had had to pay for this, it simply would not have happened without huge sacrifices on the part of our entire family. Sure, the system may be a bit broken, but at least it is civilised and reasonably fair. It always makes me a bit sad and angry that a country like the US that claims the be the most powerful and wealthy in the world simply abandons its citizens when they need help the most.

I know it's none of my business and I have no right to criticise, but I put myself in the place of other parents who simply don't have access to basic care for their kids while your politicians spend billions of dollars bombing the crap out of every country that looks sideways at them and it makes my blood boil. Sorry.
posted by dg 09 September | 06:57
I agree w/ dg and mgl - the system in the US is not working well except for those who are fortunate enough to be in the mainstream.

Some of us are stuck at a job we hate because of fear of what could happen to our health care costs if we were to be without that help (even minimal at times) from the company-sponsored plan. The stop-gap COBRA coverage is very expensive, likewise if you're self-employed; and I cringe at how expensive an individual policy can be for those with pre-existing conditions (if you can even find a policy.) HELLO you politicians who proclaim the solution is employer-based health insurance...

And, for those who have something that's out of the norm, or not covered, even when they have health insurance - there's a terrible choice to make... do we try to save the life of my loved one, or just give up because it's too expensive. That's crazy-making. When it's a chance of maintaining your life, you'll take whatever gamble is necessary. Like kellydamnit, there are a bunch of folks who've lost their life savings because of a health problem.

OK, I'd better stop now...
posted by mightshould 09 September | 13:22
What did you do this weekend? || I'd just like to assure VMA loving Americans