Re: suing self funded insurer

[Guest guest]

Dear Jenn, Good for you. I too am disabled and my employer self funded ins.

refused me too, after many appeals. I went ahead and had the surgery in Jan.

and now we are sueing the ins company. Actually I am enjoying it!!!! I had

all the same co morbids. that you have. I will keep the list posted as

things progress. My lawyer has already been to court once and the people

from the ins company didn't even show up!!!! The judge almost ruled in my

favor and had case closed, but at the last minute decided for my lawyer to

inform them that a ruling will be made if they don't show up next time. So

far I haven't paid my lawyer anything. If you can find a good attorney to

listen to you and explain your situation entirely, then you shouldn't have to

pay anything either. We are suing for all legal charges too. in

Missouri

[Guest guest]

(1) Yours is also suable under the Americans with Disabilities Act

(which is a bigger issue), because you are the employee and they are the

employer;

(2) The 20K that is needed breaks out, roughly, like this:

12K - Deposition expenses

5K - Travel expenses

3K - Misc. costs (copying, phone bill, mailing, etc.)

Please note the 20K is *not* attorneys fees and don't anybody holler at

me, thanks.

Ms Jenn wrote:

>

> Hi everyone!

>

> My insurance (ODS- Salem Hospital plan #217) is self-funded, and I've had

> nothing but problems and heartbreak with them.

>

> For reference; I'm 32 years old, BMI of 48, with multiple co-morbids. They

> include: High BP, obstructive sleep apnea, shortness of breath on exertion,

> back pain, pain in all weight bearing joints, urinary incontinence, and

> pedal edema (pitting).

>

> This started with my asking, before even applying for pre-authorization, my

> HR person who deals with our insurance if gastric bipass was covered if

> someone with co-morbidities was covered. She said, " Yes. " She even said

> that if my PCP wrote a letter explaining that the MGB is the one he required

> me to have, and that no in-network surgeons performed it, they would pay in

> network coverage. At this point I was feeling great.

>

> Dr. R's office sent the pre-authorization request. ODS did get it, and

> wanted the chart notes from my PCP. Not only my PCP, but my GYN also faxed

> to them letters of support for me having surgery.

>

> I was denied. The letter said that I only recently had been put on BP meds,

> and that my foot pain was due to the removal of a bone in my foot. They

> also stated that I didn't meet their criteria for gastric bypass. I called

> and requested a copy of that criteria and they *refused* to give that to me.

> SHEESH!

>

> I wrote up a killer rebuttal letter addressing ALL my co-morbidities and

> sent it with supporting chart notes, my sleep study results confirming sleep

> apnea, and a doctor's statement of co-morbidities. I also asked if

> she would be willing to go to bat for me. (Best decision I made!) I both

> faxed AND priority mailed this info to ODS so they wouldn't (so I thought)

> be able to claim they didn't get it.

>

> I sent all that to ODS. was able to get the appeal reviewed in a

> matter of days. After ODS said they never got anything I sent, she even got

> for me a street address and name of a person to hand deliver to.

>

> Again I was denied. this time, as in the last, the review commented only on

> two of the co-morbids... ignoring all the rest. They said bypass was

> unnessecary because the BP meds controlled the high BP, and that the sleep

> apnea was controlled by CPAP, they again stated I did not meet their

> criteria for gastric bypass. (A criteria they continued to deny me access

> to.)

>

> took it from there for me. She was able to get as far as the VP of

> claims. She got a copy of the criteria, and it basically says that I have

> to have a BMI over 40 plus had to be dying from a dire, uncontrolled

> condition. Can you believe that???

>

> Heres where the, " self-funded, " part comes in. Criteria for approval/denial

> of procedures in self funded policies are written/negotiated by the employer

> if I'm understanding right. As self funded, they are subject to a category

> of FEDERAL law called ERISA. Under ERISA the ones who set criteria/policies

> must adhere to national guidelines and standards of practice. (Please

> correct me if I'm wrong, .) This means they are in violation of good

> faith, and federal law, by setting up criteria that is not even close to

> national standards. By doing this they (the employer) have opened

> themselves to be sued bigtime!

>

> explained all of this to the claims VP at ODS. Apparently the Salem

> Hospital Board was having a big " emergency " meeting concerning my case last

> Friday. I personally hope they are terrified of being sued, which I will!

> Hopefully will hear back about that on Monday. I persoanlly (knowing

> the employer) think that the meeting was to plan their defense strategy, not

> to give me benefits.

>

> Most people are rightly hesitant about suing their own employer, for obvious

> reasons. Even though, under ERISA, you can not be fired for exercising the

> right to sue for ERISA violations, many people start recieving bad

> performance reviews and get fired anyway... for reasons that can not be

> directly proven that it is due to the lawsuit.

>

> I have an advantage... I was disabled prior to any of this, and am carrying

> the insurance through COBRA laws. (compression fracture of a bone in my

> foot.) I can NOT be fired!! *wicked grin* This makes my case ideal as a

> test case.

>

> If I end up suing, and win, this will make other insurance companies

> administrating self funded policies, quake in their boots. It will set a

> national precident. It will, from what I understand, make folks like cigna

> tow the line, so to speak.

>

> I need to raise the money needed to cover the depositions (about 800-1,000

> each), court costs, fileing fees, attorney airfare and lodging... about

> 15-20 thousand total estimated costs... I want to represent me, since

> she has had the MGB and I know this is where her personal passion lies...

> helping MGB'ers. (I need to fly her out to Washington from Alabama at least

> 3 times) I intend to sue ODS and Salem Hospital.

>

> (: I've been researching and found that Washington law allows for

> damages from the insurance company as well as the employer in ERISA cases...

> go to www.insure.com , click on, " health, " then click on, " insurance laws &

> benefits tool, " ... and bring up Washington state.)

>

> If anyone would like to assist me in covering legal expences, please contact

> me in private. Unfortunately, being disabled for a year, I don't have a

> spare 20K just laying around. (If I did, I'd have self payed by now. LOL!!)

> If I can't afford to sue, they win... and so many other folks will lose.

> This could benefit so many people, down the road.

>

> : If I left anything out, your input would be HIGHLY appriciated.

>

> Thank you for listening... and your kind consideration.

>

> Jenn in Vancouver, WA

> waiting to cross.

>

> MGB Packet approved... YIPPEE!!!!

> Denied by ODS 3 times

> case being reviewed by hospital board (doubtful, IMHO)

> hoping to set a national precident through litigation

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[Guest guest]

Thanks for clearing that up, .

Jenn in Vancouver, WA

_____________________________________________

<<<<<Message: 9

Date: Sun, 20 Aug 2000 15:22:22 -0500

Subject: Re: suing self funded insurer

(1) Yours is also suable under the Americans with Disabilities Act

(which is a bigger issue), because you are the employee and they are the

employer;

(2) The 20K that is needed breaks out, roughly, like this:

12K - Deposition expenses

5K - Travel expenses

3K - Misc. costs (copying, phone bill, mailing, etc.)

Please note the 20K is *not* attorneys fees and don't anybody holler at

me, thanks.

>>>>>

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