Well, here it finally is folks. I had mailed off my final administrator appeal 3 weeks ago..had not heard anything, so I called my husband's employer yesterday (privately owned co., and self-funded) and exchanged voicemails w/ head of HR. I had requested a live interview in my message, and she has granted it, so I go in this afternoon, and will have my answer when I leave. I don't know why, after everything I have put into these appeals, hiring The Insurance Warrior, etc., and now getting this interview, I don't have a good feeling about it. I had a better feel last night. Maybe it's just nerves. I played her message over and over, and it didn't sound like their minds were made up yet, but who knows? Interesting, no medical person makes this final determination, just HR and president of co. Yep, I guess it does just all boil down to money. Keep your fingers and toes crossed for me anyway. Say a prayer if you believe in God, or wish me good mojo all the same. http://adrsupport.org/groupee_common.../icon_razz.gif

Good luck... I am praying for you.

Justin

CindyLou,

Good luck today; I will be thinking of you, sending good vibes your direction. I hope the outcome is positive.

that is one messed up situation. I still don't fully understand it. I also don't fully understand how Laurie Todd could help you if the board you are seeking grievance with aren't even doctors?

Doesn't matter, I sure wish you the best!

Well, at the end of the day, 3 appeals later, the final one a live interview, a no is a no is a no. The HR VP lady was the only person I met with. And I could tell the minute we sat down, she was telling me the final decision was made. I expressed my confusion as to why she even brought me in if their decision was already made, and so after her speech she gave me some time to defend my position, barely. Her body language stayed closed with arms crossed tightly the entire time. I did my schtick but it fell on deaf ears. The biggest reason for "no" was still investigative, particularly because I necessitated 3 levels, and FDA has only approved 1 level for DDD....ho-hum, we've heard it all before. But they would have paid more for me to stay stateside and have a 3 level fusion. Crazy. They are conceding to paying half the total amount, but written in check form as "income," so that will be quite less than half after taxes. So, my surgery was $67,580 divided in half is $33,790, minus taxes, I'm guessing I'll clear $25,000 or $26,000. Am I happy? No. But I did my due diligence, and I'm not sure what else I could have done, minus having Laurie Todd there in person. I guess it's better than a poke in the eye. I need a stiff drink. Goodnight, Irene.

Cindy Lou,

I just introduced myself the other night and preparing for ADR two level in August. I have been checking the discussion board all day to see if you had news. I am in a similar position with a self-insured company.
To be honest, I think you did win! Although it was not the perfect outcome, you kept going until you got something. Shame on the Pres. not attending a meeting. What happened to compassion! Why did he/she not show up-out solving world issues? Right! That frustrates me to no end!
At the end of the day, you did your best and can sleep at night knowing that, I applaud your efforts and determination!

3 level fusion would've cost them much more in the US, and another surgery in 2-3 years when the adjacent disc would've gone just adds to their juvenile stance.

They'd pay half the surgery and it had to be taxable? Sounds like a big scam. I dont know of a company that charges their employees taxes on expenses.

CindyLou:

I applaud your fight. At least you did not give in, you stuck to your guns, fought the good fight and, came out with something including dignity. I am hopeful that the rest of the costs out of your pocket are settled with your tax accountant. It could still give you more money at the end of the year. This also gives you an opportunity to move on.

"Illegitimi non Carborundum" = "Don't Let The Bastards Grind You Down".

Terry Newton

Thank-you you all for the kind words. I remembered something else that the HR lady said that bothered me: that my husband is a highly compensated executive, and they have a responsibility to apply the terms of the plan fairly and consistently to all enrollees, and that if they made the exception to approve my appeal it could be viewed as discriminatory, and get them in all kinds of hot water. Wow. I did not know my husband's hard work ethic, being the company's TOP earned Area VP this fiscal year, whose regions alone brought in WAY MORE volume of sales than anyone elses, had anything to do with my surgery and medical appeal. (in other words, your husband made alot of money this year; it was cheaper to go to Germany and you got better care...wasn't that a no-brainer? just pay for it) These self-funded plans have no checks and balances, and make it up as they go along, I believe. She also said they weighed heavily on the HealthPartners Medical Directors' reviews and an external review by an orthopedic surgeon with the Medical Review Institute of America.(anyone know or heard of this review board? Justin?) I recall it was an internist who did the external review, and have requested copies of her documents. She also told me of her elderly mother who had a 3 level fusion a few years back, and is doing just fine. Hmmmm. Now I am being compared to her mother. I told her of the cost analysis I had done (remember my post asking for $$ dollar comparisons from any and everyone?) and she said good thing you went to Germany then and got it done cheaper, and you were going to go anyway to have the surgery performed no matter what, right? (so that means I still should not be compensated for it??) I could go on and on. This was my final appeal available under the company's plan, with my only other recourse being to bring a civil action suit. Yeah, right. Now let's really stir the pot and get my husband fired. He's been with the co. for 16 years, I can't do that to him. Fusion never had to face the strict trials that ADR is facing. When will they get on board?! I had just found another small study that I brought to my appeal as part of my weaponry, doing an analysis of 2 level total disc replacement with Prodisc and comparing it to 1 level cases, and the results were found to be significant improvement for both 1 and 2 level TDR alike, and that they support it as a viable treatment for 2 level DDD. (do the insurance companies and privately owned companies think we are making these studies and compelling results up?) Whew. I've ranted enough. Thanks again everyone. Something good will come from this. http://adrsupport.org/groupee_common.../icon_wink.gif

dear cindy
please just take the 33k and smile brightly as it's more then most receivedhttp://adrsupport.org/groupee_common...icon_smile.gif and in time you will feel it was money well spent.
i hope you are doing well kid http://adrsupport.org/groupee_common...icon_smile.gif
wishing you the best
chuck