Re: Thoughts on dealing with INsurance Companies.

July 24, 2000

Dear Sharon:

Have started to write this, and each time, something happens and I

lose what I typed, and have to start over again. Thanks for the very

flattering remarks, and I am dedicated to doing whatever I can to help

stop this dreaded virus, and get the word out.

You mentioned some problems that you were assisting some people

with, and while I can not provide " legal " advice, I can make suggestions

as to what I would do. My information in these areas comes from many

years of experience, combined with 2 Master's in Health Care Admin and

Business, as well as my post Master's Certification as a Nurse

Practitioner. All these initials and papers have allowed me to get to

know the system from many different perspectives, and that's what I

wanted to share and see if it may of any help.

Also, besides all my education, I have participated in many private,

State and Federal insurance investigations and have learned some of the

tricks of the trade. There are several issues and knowledge of what

makes the " industry tick " that can be used to obtain what is rightfully

owed by any insurer to it's " members " . That means using the areas that

the HMO's, etc., don't want major issues made public to be milled around

in the media, and possibly trigger a major investigation. (I was part of

the Columbia/HCA investigation, and the reason that all these agencies

started an investigation was because, while everyone in the industry

knew basically what was going on, and Columbia's ego grew, they

basically forced themselves to be evaluated. They had the reputation

that, based on size, political contacts, and " power " , they could get

away with anything. But, it was exactly this " high and mighty " attitude

that caused the investigation(s) ).

Now lets see if I can finish this before I become too sleepy. There

are certain facts that are not secret. If you are a stockholder, you

want the company to make as much money as possible. If you are a

patient, you don't care what the cost, you want the best care. While the

two sound opposite, it can be used to one's advantage.

First if you are going to talk to someone it has to be a caseworker

that also has connections to finance. If you get some " twit " , they only

know what is told to them, and you very rarely get anywhere.

Now lets look at what is in the best interests of the insurance

company, and how you can use it for your benefit. In the case of HCV, if

someone undergoes treatment for 48 weeks, it breaks down, (of course

there are differences depending on who and where), to: $ 18,000.00 for

the combo therapy alone. Almost everyone needs certain additional meds

during therapy, and that accounts for $ 1-2,000. Then there are the

labs, and depending on what and how often, you are probably going to

average $ 500-750.00 per month. Routine doctor visits will probably

average

$ 75.00 per month. Add initial tests for a diagnosis to be made,

including a biopsy, ultrasound, radiology and specialty provider costs,

usually average about $ 3-5,000.

Using the high side, this will cost the insurance company approximately

$ 35,050.00, which to any of us is a lot of money, but to them it is

pocket change.

For argument sake, lets go to the second worse case situation. They

deny treatment, you deteriorate, can not work, need frequent testing and

specialty evaluations to make sure any symptoms are not another separate

problem, and if your liver is destroyed and you are placed on the

transplant list. Average cost for just the transplant and

hospitalization will run between $ 100,000-250,000.00. Add the

medications that must be taken for rejection, potential infections,

countless blood tests and specialist care, you can probably add another

$ 2-3,000.00 a year for the rest of that person's life.

Let's say someone lives another 20 years, and the probable total

medical costs will probably run at least $ 200,000.00., which is cost

them 500% more, just in medical costs, (Oh NO, there goes the higher

profits that the shareholders want and were expecting). Take into

account intangibles such as the inability to work full time, if at all,

so they need some type of disability payments, etc. Financially, and

realistically, one person may not add up to much, but, add a hundred and

now you are beginning to talk big bucks.

Some other issues, HCV, by the CDC has been declared an " epidemic " .

While there are still fights to get disability for HCV, or Social

Security, etc., the virus has been classified as a potentially deadly,

and, to date, is a chronic disease. That leaves open litigation for

possible discrimination against a " disability " , as well as places the

public at jeopardy because it is not well publicized, and with HIV, a

precedent has been established on situations such as these. Now a single

person problems is not gong to be heard, but, a " class " , (as in class

action), will get attention.

Picture this situation:

Ladies and Gentleman of the jury, my client, age ???, was a strong,

healthy and productive member of society. He/she kept a steady job, is,

or was raising a family, was a member of XYZ clubs and volunteered in

work in a school helping out, paid the insurance premiums, and now,

(pointing to the patient) has to carry a pager everywhere in the event a

liver becomes available. Used any and all savings, including what was

slated as funds for the children's college, to pay for a disease that

he/she was stricken down with, and can no longer function without

assistance because of her condition.

He/she does not possess the physical stamina to see their child in a

School play! Is too tired to participate in the activities done prior to

becoming infected. Can Not work in a full time position, so that income

is lost. Has had to move her family because she/he needs to be close to

the hospital in case a donor is located, leaving her friends and

community behind. And, even if the transplant was not a reason, the

medical costs forced the family into a foreclosure, and lost their only

place they ever called home.

Additionally, unlike you and I, the plaintiff can not even pick up their

grandchildren or child, because of the severe weakness. The plaintiff is

aware of the fact that, because of their medical condition, they must

make the best of today, because each day the plaintiff knows it could be

their last, and they may never be able to move out of their house due to

severe fatigue.

Because of the " large " company mentality, who are more concerned with

their profits, then doing what they have been paid to do, which is to

provide care for their members. This is occurring at the same time that

XYZ company is paying their CEO, millions, and other top management

receiving outrageous compensation, the insurance company would rather

pay ridiculous management packages, and dividends to their stock

holders, then do what is expected, and promised, per their own plan.

While the managers and shareholders get to go the finest

restaurants, fill their refrigerators, drink expensive liquor, drive the

finest cars, and live in large homes, this is happening at the expensive

of my client's family watching a loved one go hungry, and deteriorate

more each day. While they struggle to feed the children first, and if

anything is left over, my client can nibble on stale bread.

Instead, while ridiculous amounts of money are spent for unnecessary

items, this comes at the expense of allowing " my client " and his/her

family to live in total poverty, as well as the fear the plaintiff could

die at any time.

This could be avoided if just a fraction of the unnecessary money was

used for providing what any " prudent " person would expect when they have

medical insurance. But, instead they would rather ignore the only known

course of treatment, and take the chance that my client will die before

a transplant is available so they can avoid those costs as well.

Ladies and Gentleman of the jury, while you hear the evidence presented

to you, please also keep in mind that my client has lost the chance for

a remission, his/her family have to change their entire lives for the

needs of my client, and even then, they always have in the back of their

minds, the children may be left without a parent and their loved one

without a spouse, all because the insurance company placed profits over

their obligations as they had promised through their own policy. "

I know there is a great deal more, but I think you get the idea. The

only thing an insurance company will be interested in, is when they can

meet their basic obligation(s) at the least cost to them. If you work on

their " pocket books " you will hit a nerve. If someone screams and yells,

they usually get the attention, even if it is to shut them up.

Another way, is to buy 1 share of stock, and then one becomes a

shareholder, or owner within the company. That means that you are privy

to all information, you can attend company meetings, vote, and,

generally raise issues that will be sticky to answer. For example, " Mr.

---, I understand you are CEO and that last year you made $ X dollars in

salary, and another $Y in bonuses and options, which totals $ Z millions

of dollars. How can you explain to the other stockholders here that with

all this income allowed to you, your company will not authorize FDA and

CDC approved protocols for a life threatening illness? Further, can you

explain why, as CEO, you would rather spend hundreds of thousands of

dollars for treatment, for 1 patient, when there is an available

alternative that is less then 1/10 the cost. Why is it that you, as CEO,

would rather take the route that will increase liabilities, and thus,

decrease what we as shareholders gain? Just to make sure we all

understand what course is being traveled, while you are getting your

salary and other benefits, you are willing to jeopardize all of us, as

'owners' and investors, by failing to act, and disregarding the

consequences, opening the door to more government regulation, facing

potential litigation, and watching our income decrease, all because the

name of our company is being allowed to be dragged and smeared in the

mud? Isn't this, not only a possible, but, probable course, from what is

occurring? "

So there are probably four areas to work on: 1. financial; 2.

discrimination; 3. political; and 4. suing. There is also asking the

State Insurance Commissioner to intervene. You may also send letters to

your representatives, as well as to the chairperson over health, in the

US Senate and House, as well as the State. One of these people should be

willing to get involved, and since this is an election year, combined

with all the issues of health care, you find the right person who would

be willing to " fast track " the issues and force the company to meet

their obligation. The last thing these politicians want is for it to get

out that someone with an acute/chronic life threatening disease is being

denied medical care, that is not " experimental " , and should be covered

under the policy. With health care being the " buzz " word these days, any

of them would love the opportunity to be able to say " ...I feel so

strongly in health care for all, that I am, as well as encouraging my

fellow colleagues, to assist in allowing access, and the highest quality

of care, that can be provided. In fact, without naming my constituent,

or the insurance company, I recently heard of that policy holders, who

had been diagnosed with hepatitis C were being denied immediate care. I

took the necessary and immediate action(s) to insure this problem was

addressed and the appropriate care was made available., etc., etc. "

If it were me, I would also send an Email, fax, and certified letter

to the Medical Director, and nicely ask for their assistance. I might

write that " on the advice of counsel... " , because, if done on a

non-immediate threat, they know you are serious, you are implying your

information is from a source that knows, and may be prepared to act,

without making a direct threat where they are backed into a corner. I

would mention that your are only looking for the care owed to you, BUT,

if this can not be resolved immediately, I will be forced to use any and

every avenue possible to gain the authorization and access to the care

stated and implied under the medical policy issued. At this point I am

only anxious to get access to care, while I still have a chance to gain

remission, as well as delay, slow, or stop the progression of this virus

before my condition may progress to a state that forces either more

damage, and/or, results in a more serious, life threatening, and very

expensive alternative course of treatment.

Less face facts, politics, negative media attention, and litigation

are the last thing any HMO wants to have is their name and reputation,

on this or similar diseases, splattered in front of the public, and

before politicians that are already looking at these issues. While I

know there are situations where insurance companies have procrastinated,

cost people their entire life savings, suffered negative long term

effects, and people have died, because their insurance company has taken

their time in approving therapy, refusing to pay for a treatment, or

just procrastinated and did nothing, that period seems to be getting at

it's end.

As Congressional Testimony has concluded, the HMOs that were

supposed to be less costly, more efficient, and allow well and sick care

for all, have gone the opposite way. They are quickly becoming aware of

all of this, as is society, and they know that if they want to survive

in any capacity, they have to do something. They are also aware that

there are State and Federal Bills pending that will force them to meet a

governmental established criteria for care, and that " Big Brother " will

watch everything they do, as well as tell these companies what they have

to do. Some may survive, but others will not.

I could go on, and probably have too much, but, these are some

things that have been highly successful in the recent past. These

companies do not want to be singled out, nor do they want a government

audit. You have to play their game, work on their fears, threaten only

as a last course, and just use whatever it takes to get what is owed to

you, or others you know. Hope this helps. Marty

July 24, 2000