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Insurance Hell All insurance-related matters are here: Medicare, worker's compensation, appeals, denials, insights, wins, losses. PRICING is here too. Note: This forum has posts from 2006 forward. Older ones are in the Big File.

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Old 06-29-2009, 01:05 AM
LBP LBP is offline
Senior Member
Join Date: Aug 2005
Posts: 446
Default How to get active re Healthcare Reform

This is a draft -proposed letter anyone could send to your US representatives re Healthcare reform:

Dear (insert Title/name):

Any Healthcare Reform must include a new law that states once the FDA approves a new drug or medical device safe and effective for it's intended use, private insurance companies may no long deny a claim on the grounds that it's still "experimental" and/or "investigational."

The current Federal Employee Benefits policy shoudl be the law of the land for all private, individual, public or governent employees plans. The U.S. Office of Personnel Management, Office of Insurance Programs issued a FEHB Program Carrier Letter to All Carriers. This Letter Number 2001-27 dated August 27, 2001, with the subject line: Coverage for FDA-Approved Drugs, Devices, and Biological Products.

Basically the current Federal Policy Letter for federal employees, explains that the Federal Food, Drug and Cosmetic Act considers a drug “investigational” until the FDA finds that there is a “substantial evidence” to prove the new drug has been proven safe and effective for its intended use. The same is true for medical devices and biological products. Therefore, once a medical drug or device is approved by the FDA, no insurance company, policy or plan may deny coverage to federal employees based on the grounds that it is still “investigational” and/or “experimental.”

Private Insurance companies should not be permitted to hold all the unchecked power to deny coverage because of some internal biased decision that a FDA aproved device is still not safe and effective for it's intended use. Why are we letting Private Insurance
Companies collect our premiums, and then when we need to file a claim for something major, they don't want to lose profits, so they use internal bias administrators to second guess FDA decisions, and continue to deny claims as 'experimental and investigational" or lack of long term data.

We need to close the loopholes of how insurance companies play games with us to avoid actually paying out claims that would and should be part of each person's standard health plan. When an insurer denies coverage of an FDA approved device, we are screwed. We have no meaningful opportunity to challenge the Insurer's decision. We need the right to sue our insurance companies in state court for negligent failing to provide insuruace coverage as contracted, and/or for acting in bad faith denying certain claims. These former state rights to file lawsuits needs to be reinstated and specifiy that these rights will no longer be exempted by ERISA law. Insureds need rights to sue their insurer as a check and balance to ensure better coverage decisions are made.

If we could get Congress and the White House on board with this concept, it could help take away Insurance Companies' broad and unchecked power to deny our medically necessary ADR surgery.

This is just one idea I thought people could draw from, cut and paste, and send to their US representatives.
Injured 9/01
Annular tears L4/5 & L5/S1
denied adr by insurance for 2 level charite as well as hybrid fusion at L5/S1 with Charite at L4/5.

New ins paid for 2 level lumbar prodisc surgery on 4/7/08 (at age 39) with Dr. Westerlund, at Core Orthop
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Old 06-29-2009, 10:13 AM
Harrison's Avatar
Harrison Harrison is offline
Join Date: Oct 2004
Posts: 7,014

Wow, that's very proactive of you! Thanks for sharing this with the community! I will print this out and read it over my lunch today.

Good effort!
"Harrison" - info (at)
Fell on my ***winter 2003, Canceled fusion April 6 2004
Reborn June 25th, 2004, L5-S1 ADR Charite in Boston
Founder & moderator of ADRSupport - 2004
Founder Arthroplasty Patient Foundation a 501(c)(3) - 2006
Creator & producer, Why Am I Still Sick? - 2012
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Old 09-03-2009, 05:03 PM
jchebert1979 jchebert1979 is offline
Join Date: Apr 2009
Posts: 66

I've sent this to every representative in my state. I also had the chance to attend a town hall meeting with a Senator where I was able to voice this opinion. Unfortunately this is only a small piece of the broken system, but thank you to LBP for taking the time to post.

I think that if you are a member of this board and recieve resources from it, you should take the time to send it to your representatives. If you do not know who your representatives are all you need to do is google "your state" congressman, senator, etc. They all have websites with instructions on how to contact them.
Chiari 1 malformation - successful surgery 1-22-09
C5-6 herniation (extrusion) with moderate central canal stenosis and bilateral foraminal stenosis.
Prodisc-C @ C5-6 5-28-09

Herniations/Buldges @ C4-5, C6-7, C7-T1, T1-2, T3-4, T6-7, T11-12
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