"get active" debate over Moore documentary

[Texas-T]

Attached is a paper my Fiancée' wrote in grad school this spring at Northwestern about ERISA and ADR. It's very interesting to learn how insurance companies are protected under a law that never intended to cover health insurance. See the quote below and attached paper. BTW he got an "A"

"According to ERISA Disability Lawyer Michael A. McKuin, “the insurance industry has, in a very ingenious way, carved out the single greatest immunity from civil liability ever devised… This absolutely removes any incentive that an insurance company might otherwise have to treat the claimant fairly.” 16"

[LBP]

Interesting read Texas T
I clicked on his sources for more info. I found
http://www.pubmedcentral.nih.gov/art...?artid=1449155 this article to be very helpful in learning about the impact of ERISA over time, and the progress and regression of our rights to sue our health ins companies by various Supreme Court decisions over time.

this is a real political issue for the upcoming election. Oprah can be a forum to get a lot of attention perhaps even with Barak Obama.

[Cat]

Hey Harrison,
I would like to respond to the Micheal Moore issue and share my insurance nightmare, but I'm not sure how to email it to you. Please advise, and I will try to get back to a computer to complete it before Thursday.
Thanks,
Cathy

[LBP]

I sent mine to info@adrsupport.org and he got it fine. It's burried in one of his prior posts here. He also says he prefers it in MS Word.

I didn't realize until just now that if you submit through Oprah's website directly, it's limited to 2000 characters!

[davidj8121]

Hello ALL,

I hear what your all saying and I agree with most of it but if you really want to be taken seriously the last thing I BELIEVE the ADR community should do is assoicate ourselves with Micheal Moore. The guy is an absolute idiot and an extremist that has never done anything for anyone but himself. Everything he says or documents is less than half the truth.

Everyone loves Oprah but she has become nothing more than a marketing machine interested only in her own self interests. At one time she really tried to help people but I do not see that to much in her programs anymore. Her show is nothing more than an infomercial of which I am sure she gets a cut of every product/person she promotes. (i.e. Dr. Phil)

If we want to get the attention of the health insurance industry lets all get together and file a $100 million dollar (or whatever the number may be ?? ) class action lawsuit against the insurance companies that are the cause of the problem. If a good firm thinks we have a case they will take it on a contingency basis ( no fee to us unless we win).

Unfortunately, in a few years, but not now, I believe that ADR will be the standard for healing back problems. I am four months out and have never, ever felt better in my life. When the time comes all of us can take a little credit for being brave enough to have our "experimental" ADR's that will eventually give the insurance industry the facts they need to deem the procedure "acceptable for coverage".

I'm sure if Oprah could help us she would want a percentage of all the ADR surgeries to follow. She is no different, if not worse, than the people you want to change. Everything is about money. If she can make a buck, sure, she'll help.

Don't mean to offend anyone but I'd rather have a law firm represent me/us than Micheal Moore/Oprah.

David J.

[LBP]

wow, I'm a little offended and it sure is easy to say all this when you're on the other side I guess. This is too important of an issue for us to fight each other over our politics.

I happen to like his prior docs and yes I'm a liberal democrat and so are many litigators... but I understand not everyone agress with his politics. But any press is good press...I don't care where it comes from if it puts the heat on the Insurance Industry.

Please don't judge this Moore project until you see it. The best thing about Moore is that he opens up controversial diagalogue. Nothing wrong with that.

Oprah does TONS of things to help people. Do you actually watch her shows? And this seems to be the year of medical issues. Something I welcome! Especially with her support of Barak as a presidential candidate.

I am pretty sure if there was a class action to be made...it would be a whole lot easier with national attention from Oprah because all the news stations would follow.

If an attorney takes this case...it will not be out of the goodness of his/her heart and bankroll..he/she will expect a huge fee, and even on contigency you still have to pay for costs to fight the good fight, up front...experts are VERY expensive...depositions are expensive, investigators are expensive...this stuff is not on contingency. Any attorney taking a case like this will be seeking a lot of media attn...and would welcome attention from the Oprah show and Moore. Plus what are the real damages for an attorney to make money on a case unless the laws change. Given the status of the Supreme Court and recent rulings re ERISA it's an uphill battle and we need all the ammunition we can get.

Putting the heat on an election year could be perfect timing.

Besides, how on earth would Oprah "take a cut" of ADR surgery? That's just insane.

[jeffdanto]

davidj8121 said it best - "If we want to get the attention of the health insurance industry lets all get together and file a $100 million dollar (or whatever the number may be ?? ) class action lawsuit against the insurance companies that are the cause of the problem. If a good firm thinks we have a case they will take it on a contingency basis ( no fee to us unless we win)."

Unfortunately, a lawsuit would just get thrown out. The reason this would happen is because of ERISA. To quote my paper that Texas-T posted above, here's an explanation of how ERISA does not allow individuals to file lawsuits against insurance agencies:

"Recent Supreme Court rulings have further interpreted ERISA to cover employer based health plans, for which the law was not intended to do. As a result of this interpretation, policy holders of employer based health plans can only sue their health plan for coverage in Federal court.

"ERISA's regulation of managed care organizations stems from its preemption clause (29 U.S.C., section 1144(a)) which states that "[ERISA] shall supersede any and all State laws insofar as they relate to any employee benefit plan." This clause has essentially "prevented states from regulating the activities of employee based health plans," which has provided health insurance agencies with more power to determine which procedures they cover while simultaneously holding them less accountable for their decisions.

"Two Supreme Court cases have further reduced the liability for managed care organizations. On June 21, 2004, the Supreme Court "effectively immunized managed-care organizations (MCOs) from liability for negligent decisions about the care of patients in private employer-sponsored health plans" in its ruling in the combined cases of Aetna Health v. Davila and CIGNA Healthcare of Texas Inc. v. Calad. Davila and Calad sued their managed care organizations under the Texas Health Care Liability Act, which is a state statute that holds managed care organizations liable for negligence "when they fail to exercise ordinary care in making decisions about whether treatment is medically necessary for a patient." Because CIGNA and Aetna are "ERISA plans", CIGNA and Aetna argued that ERISA preempted the Texas statute, and that the case must be resolved in Federal court under ERISA to recover insurance payments due for the two plaintiffs' procedures.

"The Supreme Court gave a unanimous decision that ERISA "provides the exclusive remedy for patients in ERISA plans when an MCO denies benefits – even if the denial is based on a decision that the disputed care is not medically necessary for the particular patient." Many fear that because of this decision, health insurance agencies will "have little incentive to make medically appropriate decisions if the only penalty for wrongful conduct is no more than what they should have paid for in the first place."

"According to Dr. Mike Magee, ERISA "has become the central pillar of defining the roles and responsibilities of the health insurance industry's managed care organizations. More specifically, it's used to define the extent of their liability for both health benefits and the fallout of decisions to extend, or not to extend, coverage for a wide array of health services."

(Resources:
Cornell Law School. U.S. Code Collection http://www4.law.cornell.edu/uscode/html/uscode29/usc_se...0001144----000-.html

Cornell Law School. U.S. Code Collection http://www4.law.cornell.edu/uscode/html/uscode29/usc_se...01003----000-.html#a

National Conference of State Legislatures. "Maryland's Fair Share Health Care Fund Act Overturned in ERISA Challenge" (1/29/2007) http://www.ncsl.org/programs/health/fairsharenews.htm

Hellinger, Fred J, Ph.D. and Gary J Young, Ph.D., "Health Plan Liability and ERISA: The Expanding Scope of State Legislation." February, 2005. American Journal of Public Health. http://www.pubmedcentral.nih.gov/art...?artid=1449155

Mariner, Wendy K. "The Supreme Court's Limitation of Managed-Care Liability." 2004. New England Journal of Medicine

Magee, Mike. "The Laws that Protect Managed Care" Health Politics.Org. http://www.healthpolitics.org/progra...t.asp?p=erisa)

It's quite unfortunate that this has yet to be amended. While trying to get the attention of the public through Oprah and Michael Moore may or may not be the best idea, my advice is to write your congressmen and women, and your state's senators. Explain to them the frustrations and pain you all have had to endure. Mention ERISA. Cite Texas-T's World News Tonight video to show that this is debilitating. Call your local news. There have been stories done in Florida, California, D.C., and I think Boston on local news stations about patients with back pain who have been denied coverage for ADR.

There's a lot of work to be done, but there are also many quality resources to get in touch with to help make a difference. Let's not limit ourselves to Michael Moore and Oprah.

[Texas-T]

FYI - If you have health insurance through your employer then you governed by ERISA. Any lawsuits you file against the insurance company must be filed in Federal Court where the most you could ever expect to receive is the cost of surgery - no pain and suffering. This is why the insurance companies have no incentive to cover ADR. Even if you sue after years of appealing, the most they will ever have to pay is what they should have paid in the beginning; the cost of surgery. It’s a win-win for them all around.

[Texas-T]

I think we all agree that there is problem when insurance companies can routinely deny treatments that are FDA approved and recommended by a reputable doctor. We can argue till we’re blue in the face over the solution, Jeff and I do this often as we support different political parties. The one thing that unites us though is that we want people to know that this is happening, to raise awareness so that it can be addressed. Regardless if it’s Oprah, GMA, Michael Moore, or politicians that take up the issue; if we get people talking hopefully some good will be found. Perhaps our focus should be awareness of the problem at this juncture. Once solutions are suggested by individuals, we can evaluate the pros and cons’s and better choose who to align ourselves with.

I had my ADR a year ago and I still cry when I think about how awful things were before the surgery, the hopelessness and the uncertainty caused by the insurance company. I was able to obtain coverage fairly quickly and sometimes this makes me feel guilty because there are so many people on this board who need the surgery just as much, if not more than I did, and they are forced to endure a truly screwed up process.

ADR will never become the standard of care in the US unless insurance companies start paying. Surgeons will not get the experience to perform the surgery and little advancement in the procedure will be made because people cannot afford the surgery or endure a fight with the insurance company. If ADR was covered by more insurance carriers who knows what advancements could be made; a surgeon might find newer and better ways to perform the surgery, they may even find ways to help individuals with more complicated cases or even failed ADR. The payment issue isn’t just about our individual cases; it’s about so much more.

[marilyn michalak]

I am sure that both sides agree that we need insurance reform NOW!! If you want to understand the seedy underpinnings of insurance businesses (ALL OF THEM), please read "Insult to Injury" by Ray Bouhrris. It documents just how they routinely get out of their contracts with us, the consumer. A MUST READ !!!
Marilyn
bottom three ADR Stenum '07
Still struggling with pain