If I pay out of pocket, is the ins co responsible for anything?

[Kirk]

Ask yourself a question. Is there anything I would rather do with $X than get out of this pain I am in? For me the number was $42,000 to put out up front (I did get reimbursed). Like you, I am not wealthy, but there was nothing I could have done with that money, nothing, that would have made my family and I happier than fix my back. Not a car, house, retirement fund, college fund, nothing. All that stuff can get taken care of once you have your health. Your health is priceless!

Originally posted by mmarsh:
To all: spoke to a representative at my insurance broker's office and she said if I go ahead with an "unauthorized" procedure, the ins co is NOT liable to cover any expenses. I've decided that this is too big a risk for my family's financial future. If something goes wrong, we could lose everything we've worked for over the years.

M-

[Terry]

[QUOTE]Originally posted by Kirk:
Ask yourself a question. Is there anything I would rather do with $X than get out of this pain I am in? For me the number was $42,000 to put out up front (I did get reimbursed). Like you, I am not wealthy, but there was nothing I could have done with that money, nothing, that would have made my family and I happier than fix my back. Not a car, house, retirement fund, college fund, nothing. All that stuff can get taken care of once you have your health. Your health is priceless![QUOTE]

Excellent point! End of story. Without your health you have nothing.

Terry Newton

[Terry]

Kimmers:

I am so sorry for your situation. I got denied originally by Blue Cross twice but then they ultimately paid with no intervention from me. I suspect it was one of my Board Members, who sells Blue Cross Insurance, called them and put in a good word for me.

Don't give up and I encourage you to continue the fight. If enough people stand up to them it still won't mean anything, as it is a huge corporation, but they will at least get the idea that people are willing to blacken their eye.

Hang in there.

Terry Newton

[phylly]

Kimmers,
I also appealed to the IMR and they all the physicians said the same thing-no evidence that ADR was better than a fusion. I would like to appeal further so where exactly do you turn evidence to the CA. regarding the Insurance companies, I would be very interested and have not given up yet either.
Phylly

[mmarsh]

Phylly

Do you have an HMO or PPO? Did you file with the DMHC like Kimmers? Apparently, the DOI (Dept of Ins) is for PPO's and the DMHC is for HMO's. My attorney told me that the DMHC is essentially a mouthpiece for HMO's while the DOI is an independent office. I will be filing my paperwork on Monday with the DOI. I'll let you know how it turns out.

Kimmers

Thank you again for the inspiration to keep fighting! Was ready to throw in the towel until our last conversation. Now I've got a second wind. Much of that is thanks to the encouragement you gave.

Missy

[phylly]

Kim,
I appealed to the IMR-Independent Medical Review and was denied, that was after my denial from Blue cross. I have a point of service plan, so I can use any part, HMO or PPO. I have not given up yet either, but I haven't heard of the DMHC. I will PM about the rally.
Phylly

[Terry]

I feel sorry for anyone who has to put up with insurance companies acting like God and determining our fates and financial future, all the while lining their pockets and paying their executives far too much money. It's bad enough having to heal from a major surgery let alone having financial stresses because an insurance company has determined what is best for you. Sucks Big Time!.

Do not give up fighting ladies! There are several of us behind you.

Terry Newton

[mmarsh]

Terry

Thanks for the good words! Is there anyone with a brain working at these ins offices? My surgeon wants to do ADR which will cost $22K and they want me to get another fusion which costs $77K. Can anyone explain this to me? I've already figured logic need not apply, but my goodness, who's running this asylum anyway?

Missy

[FUZZDOG]

When my surgeon spoke with Cigna regarding my hybrid adr at l2-l3 fusion l3-s1..and explained there would be less recovery time and less cost than the fusion the independant medical review "guy" replied...and I quote.....
"that does not matter"
I wish you the best in your fight.
I ended up having a fusion l2-s1 4 level and it has been a long road but so far doing ok so there is life after fusion.
I was declined the adr due to the hybrid application and being outside the fda criteria since adr at level l2-l3.
The boss of my department was also going thru a similar appeal for a prestige cervical disk one level only and met all the fda criteria. He was initially declined. He had the VP of our company intervene after giving him a thourough report of the benefits of adr over fusion in his situation. He was ultimately approved and Cigna paid for a one level prestige device I believe c5-c6.
Just goes to show even the same carrier for the same employees can come up with a different decision based on the facts. Keep up the good fight.
Coll

[Terry]

Sadly, sometimes it's not what you know but, who you know.

It was that way in my case as I had already had two denials and it got paid without appeal. I had a little intervention help.

Terry Newton