[NJ Gene]

Tammi,

This is one thing I would not rely on the board for. You have nothing to lose (except maybe a few thousand dollars) and everything to gain. You have exhausted the appeal process. Now the next step is to retain an attorney. I'm sure you can see most personal injury/malpractice ones for little to no consultation fee. In fact you can probably do a telephone consultation. At least you will know what you're up against. Who knows, maybe you will be the first person to overturn an insurance claim for this purpose and you will be setting a precedent.

If you want send me a PM with your contact information. I have some friends who are attorneys back East. While they might not have jurisdiction in CA or Ohio, they might have some helpful things to say.

One other avenue that you can try is contacting the media. Most NYC area stations have some consumer advocate who helps people with everyday problems (on WPIX, we have "Help Me Howard"; on ABC, we have "7 on Your Side"). I've seen similar stories to yours involving HMO's not wanting to cover a procedure. Usually once the media goes public with it, the insurance company quickly changes their mind because they know they're being viewed like a microscope. If you don't mind going public, this may be a good route to take. I would e-mail the station as much info as possible (copies of all medical reports, doctor's opinions, insurance statements, etc). The more the station has, the more likely they will televise your situation. If they choose to televise your story, action on the part of the insurance company is likely to be swift.

One final approach which is not as quick is to contact your local Congressman (both U.S. Senator and member of the House). Also send a letter to the editor to your local newspaper. The more publicity you get, the more likely the insurance co. is going to get wind of it. Last but not least, send a letter to the insurance commissioner of the state that's involved (I'm not sure if it's CA or Ohio). Each state has a regulatory authority that reviews insurance companies for claims they don't pay out. This is probably used more often by doctors than patients. However, they are there to serve all. They may even have an online complaint form to fill out and submit.

In summary, going through an attorney may be the best way to go. A good one may take some of the steps I suggested in the last 2 paragraphs. However, if you want to save money upfront, you can try some of the things I suggested there on your own first. Please keep me informed.

Gene