I Could Just Cry....Denied Again

[Terry]

I still think you should take the risk and have the surgery and file the claim afterwards. You only have one life. I was pushed in to that corner and it worked out (no guarantees). Life's too short. Mine was denied twice and after it was done it got reimbursed in full. I believe they saw the reality of medical necessity.

I am sorry for you and hopefully roses will come out of the dirt.

Go with God.

Terry Newton

[Jen in Brum]

Hi Karin.
What a @rappy situation to be in I don't understand the medical and insurance 'business' over there, but admire your gutsy approach! (I would be pleased to have you fighting my corner )

Keep your chin up and I hope you find a way soon!
Jen

[Nairek]

Jen,
Yeah I am a tough little chicky. I'm at a loss for (polite) words when it comes to insurance companies denying medical care to patients who need it. I am going to school to become a paralegal. With any luck, I'll graduate with my Associates Degree next May. I find it interesting to challenge the insurance companies when it comes to their denials. Kind of like doing legal research to prepare a Memorandum. Always looking for that 1 piece of info to drive the message home. Even my OS is impressed with the amount of time & research I've spent working on my appeals.
I see from your "signature" that you had a procedure done on May 18th. I wish you all the best & hope that you have a speedy recovery!

[Nairek]

Allan,
I'm really surprised that BC/BS out in California will not cover ADR surgery. I've read on this board that at least 1 if not more BC/BS plans out there have covered this procedure. Have you gone thru the appeals process yet?

Terry,
Part of my problem is that I'm not much of a risk taker. Especially when it comes to money. My gut tells me that even if I had the money to shell out for the surgery & then submitted the claim afterwards, BC/BS would still tell me that they won't pay.
I think it's wonderful that your insurance company opened their eyes & seen the light in your situation. To have 4 discs replaced & to have insurance pick it up in full is absolutely astounding! I bet you wanted to get up & dance when you found that out huh? I wish you all the best on your recovery. Please keep us posted!

[Terry]

Karin:

Where do you go from here and what are your options? How is your present quality of life and will any other options be beneficial enough to improve your level of functioning? Pain can sometimes be a great motivator though unfortunately it sometimes forces us to do that which we do not wish but what is the alternative?

I do feel lucky to have been reimbursed but feel very sad and disheartened for the many who have not been. I am angry about the injustice of it all and hate insurance companies.

Go with God and we will pray for you.

Terry and Betsy Newton

[The Insurance Warrior]

Until recently, I was "resident Insurance Warrior" mainly for my own group -- the appendix cancer people. Long story short, I walked into my doctor's office with a metastasized abdominal cancer, and my oncologist told me, "There is no treatment for you. And, if there were, they wouldn't pay for it."

I didn't take kindly to this, found the world's expert on my cancer, fought the Clash of the Titans with my insurer, and made them pay it all.

Two years later, I run a mile a day, take no medications, and remain thus far cancer-free.

I have gone on to win between twenty and thirty of this appeal battles with people. So far, I still haven't lost a case.

The first thing I learned, when my life was so urgently on the line, not to take any of this personally. If I had given myself over to rage, while also going through two gigantic abdominal surgeries and intraperitoneal chemotherapy -- and also fighting my insurance company -- I wouldn't have prevailed, and I wouldn't have survived.

It's not personal. It is simply their job not to pay, and your job to make them pay.

I appreciate the strategy of getting the treatment first, then sueing to make them pay for it. Why? Because THE ONLY THING THAT MATTERS IS THAT WE GET OUR TREATMENTS. The terrible fights with the insurers are only a very high stakes game.

These appeals are not won based on the rightness of our cases, or on the amount of information they contain. We win them based on our ability to write an extraordinary persuasive legalistic document that makes them fear that we might be a lawyer.

What is the one power we have to make insurers pay for something they don't want to pay for? THE POWER TO SUE THEM. Why do they not want us to sue them? After all, they have plenty of lawyers to squash us like a bug. Because they don't want these lawsuits to become public record. How do you think I concocted such a smart bomb of an appeal? I spent two months poring over lawsuits against HMO's. Borrowing their scary language, copying their arguments.

Now, mind you, we aren't going to actually sue them. We are going to intimidate them. As one of my helpees who is an ex-boxer said, "Oh, now I understand! A bluff-down is as good as a knock-down." Right on brother, couldn't have said it better myself.

By the way, as more people find me, I have branched out and done carcinoid tumors, breast cancer, testicular cancer ... even a stray L & I case. Same objections, same strategy. It is the same story: If it is expensive, your insurer has a hundred secret ways not to pay for it."

For me, the monumental insurance battle turned me into a force to be reckoned with.

The Insurance Warrior is in the house.

Laurie Todd, the I.W.