suing self funded insurer

[Guest guest]

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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