KAISER DENIED MY CLAIM

[chuxk79]

I just got back from a drive up to Santa Cruz to
visit friends and the drive didnt bother me at all
In my legs or lower back ,yahoo
Now on to my Subject. Kaiser says because I elected to have surgery in Germany that they dont consider it a Emergency.
Kaiser says an Emergency medical condition is a medical or mental condition which has accute symptoms of sufficient severity(including severe pain) such that a prudent layperson who has an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

Placing the health of the person in serious danger,or
Serious Damage to body functions, or
Serious disfunction of any body organ or part
(whew) and Im a 2 finger typer

Well when you have been in Severe pain for years
to where you almost feel suicidal and years of laxitives and stool softners may damage your bowl function and you are succeptible to liver or kidney problems from all the different kinds of meds you take over years, I think that I fall into these catagories above.

I sent Kaiser a 32 page letter explaining alot of these views including how much money I will save them in narcotics by being off them but now I guess I will have to APPEAL!!!! Any Ideas on how I should approach this will be appreciated.
Should I get an Attorney?? Anyone who has dealt
with the appeal process and won, Let me know.
Chuck D

[Harrison]

Chuck, fight to defend your health! What do you think the right course of action is medically -- and are they denying you this? I think I know the answer...just wondering if you have the specific medical solution planned.

Lot of folks have appealed and won, but much of them seem to be won through sheer tenacity or luck. Some of the recent wins have been more formulaic (Tim, Leanne), feel free to email or PM them asking for their help.

Hang tough, do the right thing for your health!

[chuxk79]

Harrison
I made a call to member services and so far from what they have told me that the appeal has to be made by MAIL, I'm hoping that at some point in the appeal process I'm able to appear before a
board of real people.
This denial was just recieved and I probably
will send a copy of the 32 pages I already sent
to the claims dept and now will send it to the appeal dept. One of my points was all the money I will save them in the cost of Meds,celebrex alone is a very expensive drug if one pays out of pocket, and yes I know about warnings about celebrex so nobody needs to post the warning, not
to mention their cost if I would have elected to
have FUSION surgery.
Thanks for the reply
Chuck D

[Kim]

Chuck
Just wanted to say good luck on your appeal. I am in the process too and know how frustrating it can be. I can only hope and pray that more insurance companies come on board as time goes by and we all get the surgery we desperately need.
Kim

[Rein]

Chuck

Don't mean to be a downer, but every person I've seen so far who has posted about making their final appeal in person has reported that it was pretty much a waste of time and they only got a couple minutes to make their case. My take on this was that if you can't make the case in writing then no amount of personality or personal appeal is going to make a difference.

I'm curious about why you are asking for insurance coverage of ADR under an emergency clause. It's a surgical procedure and should be covered under another clause in your contract which would allow something like fusion. I wouldn't have assumed that they *would* have covered it as an emergency procedure, because it isn't. Of course, to those of us who have been in pain for long periods of time and don't have a real life due to the effects of damaged discs, it certainly may seem like an *emergency* sometimes!

[chuxk79]

Rein
When I first called Kaiser about my Surgery
expenses they said the first step was to fill out an emergency claim from ,shortly afterword I recieved a letter requesting copys of travel reciepts giving me the appearance that I had a possible chance. I have been waiting for some
hospital info from Germany but even though It
hasn't arrived yet I still got the denial. I would think that saving them money as I previously
stated in my other post would at least get me some
monetary relief but I will appeal when my Hospital info arrives and see what the appeal board says. At least I was approved for Social Security disability while I see how my body continues the healing process.
Take Care Chuck D

[ans]

Wow Chuck, it seems like you fell into some kind of trap/ambush and that you were bs'ed. I'm sorry to hear this and I would complain that you were misled. I'm sorry I cannot help more..

[chuxk79]

I just sent in my appeal letter to Kaiser yesterday. I made my case based on their defination of emergencys and also mentioned how I saved them tens of thousands of dollars for example of opting not to be a possible candidate
for a morphine pump implant. I'm sure they will probably awnswer #^*$k you very much, but we wiil
see.
I can't believe more people havent given their opinion on my other post about putting insurance
companys in their own name catagory since there
is so much talk about Insurance, hopefully we will
get some more feedback.
Feeling pretty good at 5 1/2 months after my 3 level but I need to get more on the excercise
program.

Take Care CD chuxk79

[Rein]

chuxk79:
[qb]
I can't believe more people havent given their opinion on my other post about putting insurance
companys in their own name catagory since there
is so much talk about Insurance, hopefully we will
get some more feedback.
[/qb]

Your idea certainly has merit and will be more efficient than what we've got going right now. If you can hold off a bit longer we're actually in planning mode right now for a new, separate topic category devoted entirely to insurance issues. Hopefully, most current insurance threads will be brought over to the new category. "Stay tuned for fancy-dancy new improvements to the ADR Support Forum!"

[chuxk79]

Sounds Great REIN
CD