Fighting your insurance

[Guest guest]

Another periodic post:

You can fight your insurance company and win

The author of this article preferred to remain anonymous.

Patients must often do battle with their insurance companies. In one case, the patient's company hired two consultants to dismiss her Lyme diagnosis. She was frantic, not knowing how to fight them. Whatever you decide to do, and no matter what the basis of your denial may be, make sure that you READ YOUR POLICY.

There may be a specific procedure for appealing denials and you must follow it. Be aware of time limits. Also see if they specify a time limit for their response to your appeal. If you don't follow procedure, some companies will simply ignore you and hope that you will go away, or that the time limit for you to file properly will expire. Sometimes there is no choice but to hire an attorney.

I had a problem in New Jersey which I feel is fairly universal. This article will describe my strategy for beating your insurance company at their game of denying you benefits for your legitimate medical needs.

The tactic that the insurance carriers use is typically something such as: " It is the opinion of consultants that the treatment provided is experimental and does not fall within the scope of your coverage.... " or, " It is the opinion of our consultant that adequate treatment of (usually 28) days has been provided. There is no indication for additional treatments... " or, " The drug is not approved for Lyme disease.... "

Your response to this must be in stages in order to set up the paper trail. Don't accept a " no " from an employee with no authority to say " yes. " Deal with the decision makers, not the clerks. Keep copies of all your correspondence.

Your first letter.

Respond with an appeal letter stating that you have performed a review of the peer-reviewed medical literature and have found the following:

a. There is no clear consensus as to what constitutes appropriate or adequate treatment for LD. There is no gold standard. The treating physician's clinical decision must be regarded as acceptable in each individual case.

b. While some of the literature does indicate successful treatment after 28 to 56 days in cases of early infection, there is a vast amount of support in the literature for prolonged antibiotic therapy in cases of chronic LD, multi-system infection, and especially neruoborreliosis.

c. Surely your consultant must be aware of these references. If s/he is not, I will provide them for you.

Either you will get no response at all, or you will get another denial. It is time for your second letter.

Your second letter.

a. With your second letter, provide specific references (For a bibliography of 50 articles supporting the notion of persistent infection despite antibiotic treatment send $1.00 and SASE to the Lyme Times Editor, PO Box 1423, Ukiah, CA 95482.)

b. Demand to know the name of the consultant and the references s/he cites in arriving at his/her conclusions, which deny your claim.

c. Copy everything to the insurance commissioner of your state with a letter stating that your insurance carrier has violated its contractual agreement with you and has denied you benefits for medically necessary treatment, despite your having met your obligations by paying all your premiums on time. Make sure you letter to the insurance company has " cc (Name) Insurance Commissioner " at the bottom.

Your third letter.

Write another letter stating to the insurance company:

1. My claim has been denied on the basis of a selective review of the literature which has been carefully selected to support the bias of your consultant in order that s/he may recommend denial of my claim for medically necessary treatment.

2. The denial of coverage was arbitrary and capricious and was not based on the available medical literature. It is apparently the personal opinion of the consultant. It is obvious that this tactic was used only for the financial benefit of (Name of the insurance company), his/her employer. Your denial of coverage has caused me great stress and personal harm.

3. Based on this, and due to your recalcitrant position in failing to honor your contractual agreement with me, I have done (or will do) the following:

a. File a formal complaint with the commissioner of insurance.

b. File suit against the insurance company for breach of contract in which I will seek punitive damages.

c. Contact the state attorney general in order that a federal investigation of possible racketeering may be instituted against both the insurance company and consultant.

d. File a civil action against your consultant or consultants, their employers and all associated individuals for personal harm. I have been informed that their actions will not be protected by their malpractice insurance as I have made available to them a multitude of citations from the medical literature in support of the need for my treatments. They have ignored the accepted medical literature in order to perpetrate a fraudulent assessment of my medical condition for their own financial gain. I have consulted with counsel and am assured that my suit will be successful and likely to incite others to a major class action suit against these consultants personally and you as a licensed company in this state.

e. You have 10 days to respond.

I have a series of letters in my office in which I have done essentially as I have described above. Recently $17,000.00 in past due medical bills were paid.

(This article is from the April/May 1997 issue of the Lyme Times)

[Guest guest]

Hi, Vicki,You are covered by ERISA if your company chose to pay for and manage their own employee benefits plan. They, in effect, become the Plan Administrator and hire a Third-Party Administrator (in our case, First Health) to be the Benefits Administrator. However, the Plan Administrator (the HR Benefits person at your place of employment) does have the power to override the Benefit Administrator's (First Health) decision. They can tell them to go ahead and pay -- that is, if they are ethical. (They saw how much my treatment was costing and were not going to get themselves on the hook for ' treatment. As secondary payor under my employer's benefit plan, they had no choice. This is called Coordination of Benefits. They have to pick up a portion of what my plan did not pay.)

First Health is NOT an insurance company, which is why they can't be sued or reported to the state agencies. The state only arbitrates INSURANCE companies. Employers go with these plans to cut down on their health-care costs (payouts). They usually adopt this plan if they have a lot of young employees and they feel they won't really be paying out very much in health-care costs, but will be collecting a lot of money in premiums. It's really a gamble for them.

The Third-Party Administrators (like First Health - we refer to them as "False Hope") are basically hired to find every way they can to avoid paying out any benefits, because your employer collects insurance premiums and invests this money. They also get some government kickbacks for "providing" these benefits to their employees. I don't blame you for not understanding how it works.

Note: ERISA stands for Employee Retirement Income Security Act. They threw in insurance later on, but it was intended only to protect retirement benefits -- never was designed for insurance stuff.

That's also why we can't go to the State for protection. Employee-sponsored plans are covered by ERISA, which is, indeed, a very old plan and was never intended for this purpose. (ERISA is governed by the U.S. Department of Labor.) It sort of evolved. But to try to change the law would mean reorganizing it all. As I said, more than 65% of Americans are now covered under ERISA plans (meaning employee-sponsored plans). Until they get sick, they never realize that they are paying out good money every month and most likely won't see much in return and have no way to resolve unpaid claims, like you can with a bad-faith insurance policy. Even if you do manage to prove bad faith, there are no monetary awards. So....they can delay forever, and count the money saved on this year's profit sheets, which they proudly show off to investors.

We have looked at First Health's marketing site, and their number one selling point is that they SAVE THE EMPLOYER MONEY BY DENYING CLAIMS as often as possible. This is their selling point to companies looking for a Third-Party Administrator to deal with their claims handling. ERISA plans are not an HMO and are not a Managed Care type of benefit plan (they can't even use the word Insurance Plan -- they are a Benefit Plan).

has been denied 2g of intramuscular rocephin twice a week because, according to their "experts," it is impossible to ERADICATE (ha, ha) Lyme using this dosage and this means of delivery. The other denials are so laughable, except that it is sad. Like I said before, has suffered a needless disability because he was denied the necessary early treatment to prevent progression of the disease.

They quoted other experts from outmoded medical texts, even though we quoted Conn's (Dr. B's input)and even cited one reference in a publication that hasn't been released in that publication number yet. They just picked a number out of thin air, I guess. It doesn't exist. Conn's Current Therapy is THE Bible for all treating physicians. If you didn't know anything about a particular illness, you would refer to this publication for answers. Dr. B wrote the section on Lyme.

Hope this helps some. It may be oversimplified, but it is quite confusing. Try ' site again, and maybe this will help clarify what we've been fighting all these years.

P.S. Now that First Health is my primary payor (I ran out with my old company), I am encountering the same C--P from them. Just another new fight we have to undertake.

Keep singin', keep smilin', brighten someone's day today,Rose

Vicki Ferraro <ferraroa@...> wrote:

From: "Vicki Ferraro" <ferraroa@...>

Rose,

I read 's site about ERISA along time ago. But I really don't understand how it works. All I understand is that it is a very old law. Which means it is buried deep in bureaucracy and hard to fight. But I'm willing to fight it, from what little I do understand, its not fair and needs to be changed. Who does it protect? The insurance companies, and if so, just particular ones? I know I very ignorant as to what its all about, if you could shed some light on it, maybe I could try to fight it better. How do you know if your insured through an ERISA plan?Vicki, Md

..

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[Guest guest]

Rose,

I read 's site about ERISA along time ago. But I really don't understand how it works. All I understand is that it is a very old law. Which means it is buried deep in bureaucracy and hard to fight. But I'm willing to fight it, from what little I do understand, its not fair and needs to be changed. Who does it protect? The insurance companies, and if so, just particular ones? I know I very ignorant as to what its all about, if you could shed some light on it, maybe I could try to fight it better. How do you know if your insured through an ERISA plan?Vicki, Md

From: " J. 'Rose' Rose " <therosewriter@...>

Hi, Marta. This information is great for everyone else. No help whatsoever if you are covered by an ERISA plan. (Sixty-five percent of Americans are covered by ERISA. It's basically a fraud. They take your money, and then don't pay for services rendered.) Been down that road many times That's how our website got started. With ERISA, no recourse. No reason for them to pay if they don't want to do the ethical thing.