In November I was diagnosed with acromegaly (A type of brain tumor, 3 in a million people get). I was told that my condition was advanced, that every second that the tumor was left in my head it was growing and causing blindness, heart problems and finally death and that I needed surgery as soon as a qualified surgeon could do it. A qualified surgeon is the key word. Not many people in the US are qualified to do this surgery. I went to see a local neurosurgeon and was told that he was not able to do it, I then asked if he knew of anyone in my network, he stated no, that I would have to go to a center that specialized in these types of tumors.
We discused centers, such as Mayo, Cedar Sinae and M D Anderson in Houston. Because Houston was closest to my home and could do the surgery in a timely manner, my doctor recommended that I go there for my surgery. I then went through the process of trying to get a pre approval for my surgery, which was a nightmare with my insurance company. First they said they had no Medical Director and that the process takes 45 days to complete. I then explained that I did not have 45 days to waste waiting on trying to get a answer and could possibly go blind or die while waiting. I spent 3 hours on the phone begging for help, being switched from person to person and was told by each one that if they were in my situation, with a small child at home, they would go have the surgery where my doctor told me to go. But they said there was nothing they could do to speed the process up. I called MD Anderson and spoke of my situation, I was told that every insurance has a medical director and that I was getting the run around. That this was a time to spend with my family (because it could be my last) and to get a advocate to speak to my insurance for me.
I did get a friend to act as advocate and as soon as she mentioned a law suit, guess what they did have a medical director and they could speed the process up. Calls were made within the next 2 weeks to check on the progress of their decision and we got no answer. It wasn't until I was in Houston getting ready for my surgery that I found that they denied my claim. Saying that they didn't consider it to be a emergency to have the surgery or I should have gone to a local emergency room to have my brain surgery. I was told that I had an appeals process and if they were in my situation they would have the surgery and worry about it later. At this time I felt like there was nothing else I could do. I was there with a doctor that was ready to do my surgery and was told that every second it was left in my head it was doing my body damage so I went ahead with it. The care that I received was excellent and although my tumor had grown even larger than expected in a short time, I've done better than expected. Most with tumors my size have to have radiation treatment and expensive shots each month and drugs for the rest of their lives.
Now they are saying that they found a doctor in my network that would do the surgery. Where was this information when I was begging them for help? My surgeon charged $17,000 for my brain surgery (which I was told by other doctors that it was normal because of all the years (15) of schooling that have to be completed before preforming a surgery like this), my insurance said that $2,000 was normal and accustomary, so they paid $1400 towards my $17,000 dollar bill. The insurance commission of Oklahoma told me that I was not allowed to sue the insurance company when I requested their help. What is a person to do? I followed their rules, I guess they are upset that I didn't die. I would have preferred to have it done closer to my home if I would have had the same results and a qualified doctor. They did not give me this information when requested.
I filed my appeal claim and they stated that I was self referred to MD Anderson and that I was referred to Emery. I told the insurance commission that I was not self referred and proved it by providing doctors proof. And I was never told about Emery. Which by the was after hearing this I checked, it is in Atlanta Georga, and it isn't in my network either. I told the insurance commission this and she said that she knew this analyst that was doing my appeal for the insurance company and would discuss this with her. I just received a letter from the insurance commission of Oklahoma saying that her talking with the analyst about my situation resulted in my final (second) appeal which was denied, and that I had no legal recorse and was responsible for the out of network bill. This second appeal wasn't even in writing. Any suggestions on dealing with this crooked company?
Thanks, Assurant Health victim, Fortis Insurance, Time Insurance
Jill
Grove, Oklahoma
U.S.A.
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