MIMAWELIZABETH
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Insurance Company Woes

Tuesday, December 11, 2007

Have I got some insurance stories that are real doozies...
I finally got help from my medical group (it was the medical group bureaucrats that administered the insurance and not the insurance itself that was - how to say? being idiotic?!?) by contacting a lawyer, learning about medical malpractice, and writing a letter myself threatening to sue them.
I met with the owner of the medical group company and his lawyers, he appointed a patient advocate to guide me (who truly was on my side), and immediately got me transferred to see a new doctor (the best one in the practice).
Because they willingly did all they could to remedy what had gone wrong; and most of all, because my condition isn't "fixable," so their delay didn't cause me additional damage (no proof to the contrary legally), there was no malpractice suit. In any case, I didn't WANT to sue them, I wanted proper medical care!!!
Still, some things were like pulling teeth. For example, I was using a wheelchair (I had to buy myself), because I was too unsteady on my forearm crutches. (Store personnel get pretty upset when you fall down in their stores!)
My new doctor requested a walker, the kind with a seat and wheels, as a way to work myself out of the wheelchair. I started with the metal frame one they sent, and wore out several sets of tennis balls walking 20 mins here, 30 mins there, building up my strength.
The metal frame one though, was really hard for me to manuever, and I couldn't carry my purse or any bags... I fought nine months and went through appeal after appeal to get my current walker, the one that has given me a real independence.
AGAIN, it wasn't the insurance, it was the medical group. Problem is, I couldn't go to the insurance company to complain and appeal the negative decisions until I had exhausted the medical group's bureaucracy. Their denials were pure stupid greed. Plus, if they said no long enough, I'd go away, right?

So, here's my "funny" story: My patient advocate and I were really raising a ruckus about the walker, so the head of the appeals committee called me personally to explain the last denial.
She said the "deluxe walker with seat and hand brakes" was denied because they wanted me to stay on my feet and not be tempted to sit down... I told her, you know I'm in a WHEELCHAIR, right??? I'm too unsteady and fall when I try to go out and use my crutches - the walker is to GET me on my feet, get it?
She stammered, and then said, maybe you can have a person follow you around with a chair, so you can sit down when you're about to fall. After a second to digest that, I asked her, you mean one of my kids should follow me around the store carrying a chair??? You mean at Lucky's and Target and Savon???
SO, I said, look, no hard feelings, this is the final denial from your medical group - now I go to the insurance company to complain. Send me my final denial letter immediately. For the next week, we hammered them for that necessary letter - my advocate called and reamed them at least twice a day - but it was run-around after run-around.
Then I got a call from a medical equipment company asking me what color I wanted for my deluxe walker, which they would be delivering that afternoon. I told them they had the wrong person! ...but no, it was for me. I called my advocate and told her, and she about blew a gasket!
After that, the rest of our requests/demands were responded to quickly, and I finally got the referrals and testing and physical therapy I needed.

Now I have a new insurance, and the people who administer it are raising irritation to a new level. My C-Pap broke down and the respiratory company immediately delivered a loaner. To get a new one, the Ins Admin said I need a sleep study. So my doctor did the request and scheduled it at the authorized hospital lab.
Luckily, they checked with the Ins Admin first, who said the sleep study was NOT covered. They said my doctor had to request the sleep study and justify its medical necessity - just ordering the study on the basis of I've used a C-Pap for eleven years and need a new machine to replace it (despite the fact that THEY are the ones who are demanding the study be done in the first place), wasn't enough. (WHAT???)
So he's sent three letters to the ONE person who handles these requests, and they all disappeared down the black hole of ???
Now an ENT my new doctor referred me to is working on it. Her nurse said she'd called the Ins Admin, and figure out how to move the process along. Well, she just called me and said she had no luck trying to work with the insurance - the administrators - to even get the information needed to MAKE the request.
Now what? Our insurance coverage is excellent, it's the getting it properly that's hard.

WOW - what a vent! Not all is terrible, maybe I shouldn't be so irritated by these incidents. When I had cancer years ago, the first medical group gave me absolutely outstanding care, with no delays and ample outside referrals and follow-up care. With the current plan, my husband and daughter also receive/ have received medical care above and beyond.
Still.....!!!
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Member Comments About This Blog Post
  • BJUMPINGFORJOY
    I know what you mean it seems that a person has to close to death before you can get help sometimes I think that it is not worth it but you have given me encouragement by your fight and courage you are to be admired.
    3960 days ago
  • DOITFORME4
    OOOOh, aren't they just greedy xxxxx. The funny thing is, as individuals they're not so bad. It's the system. I've always said, they are so scared of being ripped off, they spend far more trying to protect themselves, than they probably save in the long run.

    Never mind -- you,my dear, are magnificent. Keep fighting em. You're right, you often have to play their nasty games to win. (Mind you, I'd probably write to the owner of the company, reminding him of what happened before and telling him re all these roadblocks being put in your way. It does occasionally pay to go right over everyones heads.) You know --you probably would make a great advocate after this.

    Keep working on your mobility. You will beat the physical restrictions and them the way you persevere. Remember, small, tiny, baby steps pave the way for bigger steps later.

    Hugs to you for hanging in there. Too many give up and that only encourages them to keep things the way they are. There should be more like you.

    Karen.
    3961 days ago
  • RESERVED1948
    Good for you and your persistence in getting what you need. It is terrible that you have to go through so much difficulty. I am very pleased that you have a good patient advocate. I also notice what a fine, intelligent lady you are. I do hope through the power of healing of Jesus Christ that one day you have no need for this deluxe walker. I hope and pray that one day you can just throw it away. Perhaps there is a reason that you are going through all this. Perhaps, one day, you will be a patient advocate or in some other way assist others with your knowledge and intelligence. God bless you and Keep The Faith!
    Irene
    3961 days ago
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