Insurance denial?

[steve1 5]

I found out recently that my insurance company is denying coverage for the cancer treatment I want. There reasoning is that there are other treatments that are cheaper and supposedly just as goodl. The other treatments often have god awful side affects which I don't want.

I've got postrate cancer. I did a lot of research and found proton radiation treatment. It's the best. It has about a 95% kill rate on the cancer I have. It is not an experimental treatment. It has been around for over twenty years. Some insurance companies pay for it, but others don't. It is about twice as expensive.

Any suggestions on what to do? I can't wait months and months to hagle with them. I can file an appeal and then wait 60 days for them to get back to me. I talked to two insurance reps. yesterday who said it is almost a sure thing to be denied again. What a nightmare!

[Nataly 38]

I'm not sure if this is of any help, but one of my accounting tutors used to work for AXA... He told me their policy was to deny coverage until the 3rd or 4th contact and then only gradually release funds until the person complained enough times that they knew they wouldn't give up...

So you may be entitled to reimbursement for the treatment even despite what you are being told.

"There is no problem so bad you can't make it worse."
- Chris Hadfield
« Sors le martinet et flagelle toi indigne contrôleuse de gestion. »
- my boss

[Amazon 7]

Welcome to my world Steve

I am sure an insurance executive will get a great bonus check this year with the money they are saving in denying us coverage.

[Amazon 7]

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I'm not sure if this is of any help, but one of my accounting tutors used to work for AXA... He told me their policy was to deny coverage until the 3rd or 4th contact and then only gradually release funds until the person complained enough times that they knew they wouldn't give up...

So you may be entitled to reimbursement for the treatment even despite what you are being told.

And by that time your credit rating will be destroyed by medical bills that you can't afford to pay out of pocket. OR if you dont want to go bankrupt you just don't have the needed operation or operations.

[Nataly 38]

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I'm not sure if this is of any help, but one of my accounting tutors used to work for AXA... He told me their policy was to deny coverage until the 3rd or 4th contact and then only gradually release funds until the person complained enough times that they knew they wouldn't give up...

So you may be entitled to reimbursement for the treatment even despite what you are being told.

And by that time your credit rating will be destroyed by medical bills that you can't afford to pay out of pocket. OR if you dont want to go bankrupt you just don't have the needed operation or operations.

Yep... This practice should be banned and considered criminal. I don't want to hyperbolise, but I'm sure people litterally die because of it.

"There is no problem so bad you can't make it worse."
- Chris Hadfield
« Sors le martinet et flagelle toi indigne contrôleuse de gestion. »
- my boss

[oldwomanc6 60]

This sucks!

You are definitely between a rock and a hard place.

You say you can't wait till it's resolved with the insurance co. to seek treatment, so I guess the question is: how much is your life worth to you and your family? Is it worth going ahead with the possibility of no return on the money invested? Normally, I'm one of the last people to suggest a lawyer, but sometimes you just gotta do what you gotta do. A lawyer (who knows his way around the subject--not just any lawyer) may sometimes be the ticket to getting the ins. co. to pony up.

Good luck to you, whatever route you end up taking.

lisa
WSCR 594
FB 1023
CBDB 9

[regulator 0]

My mother had the same insurance company for her medical insurance for well over 25 years. Paying in the range of tens of thousands of dollars a year (my parents were self-employed) and never making a claim. 5 Years ago my mom was helping my sister move and she stepped off of my dads flatbed trailer and scraped her ankle very badly and had to be rushed to the hospital to have over 50 stitches in her lower leg. As soon as the claim was paid out they dropped her policy like a hot potato. At least they didnt deny her claim, but in my opinion of someone that probably paid those asshats close to $100,000.00+ them cancelling her policy is totally chickenshit...and apperantly it happens all the time.

[JerryBaumchen 1,434]

Hi steve,

Very sorry to hear.

Welcome to the world of profit driven free enterprise medical coverage.

I have friend who did the radiation treatment and it seems to have worked.

I wish you the very best; my PSA just shot through the roof. Who knows what tomorrow will bring.

JerryBaumchen

[steve1 5]

It might be good to get a biopsy done, Jerry. My PSA jumped from five pt. something to 9.1 in just a few months. They bored 12 holes in my postrate. There was cancer in four of them. It's no fun turning into an old fart!

I hope there is nothing wrong. It could just be an infection or something else.

Check out proton radiation, if you need it. Your insurance might pay for it. Mine is about worthless. I might have to settle for some treatment, that I really really don't want.

[Nightingale 0]

Check your state's insurance board or department of managed care. There may be an appeal process that your doctor can help you through. I did this in CA when my insurance denied my migraine treatment. They paid.

[JerryBaumchen 1,434]

Hi steve,

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It might be good to get a biopsy done, Jerry. My PSA jumped from five pt. something to 9.1

Right now he has me on antibiotics as he thinks it could be just an infection. Three more pills to go then I have to contact him; probably more testing to see if anything has changed.

My PSA went from ~4-5 to 8.4 or so.

Yes, I'm thinking biopsysies are next.

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It's no fun turning into an old fart!

There is good and there is bad. The real problem is that nobody told us about this stuff when we in our 20's.

JerryBaumchen

PS) Unless I get some very strong advice, I long ago decided that I would go the surgery route. Life is all about 'Ya takes your chances and . . . '

PPS) You young folks getting tired of us talking about this yet?

[ffp1974 0]

4.5 is considered high.

[Andy9o8 2]

Steve, first of all, I agree that you should lawyer-up, and do so immediately. But I also know that pursuing insurance claims, even if you were to file a lawsuit in court tomorrow, could take quite a few months at the minimum.

I'm just very worried about the medical effect of your waiting for your claim to plod its way through the system. Is there any way you can get the doctors, etc to give you the treatment now, while your insurance claim is still pending?

I'd urge you by the end of this week to have this conversation at some length with both your own doctor, and a lawyer well-versed in representing policy-holders in insurance claims. Please don't delay.

[Krip 2]

Hi Steve

We've all seen the movies aboout the evil insurance co's, Not wanting to pay for their defination of expermital treatments:

Deny, deny until they die

Couple of thoughts: The clock it ticking

Negotiate with the hospital to accept insurance and a very long payment plan.

VA

Will the insurance co pay the usual customery fee and you could come up with the additional $$ via CC and make minimum payments.

Lawyers take time and $$$. Don't know if they will take a case like this on contingency.

Have you considered looking into treatment oversea''s.

Good luck
R

One Jump Wonder

[steve1 5]

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PS) Unless I get some very strong advice, I long ago decided that I would go the surgery route. Life is all about 'Ya takes your chances and . . . '

I'm still thinking of that too. That surgery is quite an ordeal. The wrong sureon can really mess you up, so you need someone very experienced.

If the cancer comes back they can then do radiation. It sounds like you can only have radiation one time, then you have to go on female hormones which chemically castrate you. Some people choose to be castrated because it is cheaper. The thought of that scares the hell out of me.

I friend of mine's dad had seeds implanted in his postrate. Then the cancer came back. He chose to die rather than take the female hormones.

So, I want a radiation treatment that is going to work. It sounds like if it doesn't work the first time, you don't have many choices left.

Proton treatment has like a 95% chance of stopping the cancer, if it is in the early stages. I heard that the old school, external radiation, has about a 78% chance of stopping the cancer. When you're fighting for your life, those percentage points matter. It seems like most people who have the external radiation, have the cancer come back.

My Dad had his postrate cut out. He later had infection problems. He wore a urine bag for four months. There was a long recovery time. Then the cancer came back. After that he had radiation treatments. He came out of it impotent. He may have had other side affects too.

What scares me, about surgery, is that I heard that 60 to 80 percent of men come out of it, impotent. I'm still a wild stallion at heart! Robotic surgery may be somewhat better, but they are still cutting all kinds of nerves and blood vessels down there.

If I'm wrong about any of this, please let me know. I need to write an appeal tonight. I'm probably going to have to settle for an old school treatment with lot's of side affects.

I appreciate everyone's imput on this....

The good news is that postrate cancer normally spreads slowly. It is a killer though. Once it gets in your limp knodes you are probably going to die. One guy waited three years before he could get better insurance and then receive Proton therapy.

I hope to get another PSA test tonight. My PSA about doubled in three months. I haven't had it checked for about six months.

[mpohl 1]

Sorry, but that's the sad state of healthcare affairs in the US.

Unbeknownst to many, more than 36,000 ppl a year die because of lack of access to adequate health care. That's one 9/11 every month!!!

Also, see here for today's news: http://www.cnn.com/2013/01/09/health/international-health-report/index.html?hpt=hp_t2

P.S.: One can only appreciate the absurdity of healthcare in the US, after having experienced how it is done in other countries. I have received much better, much cheaper healthcare in Europe and the Dominican Republic (a so-called third world country).

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I found out recently that my insurance company is denying coverage for the cancer treatment I want. There reasoning is that there are other treatments that are cheaper and supposedly just as goodl. The other treatments often have god awful side affects which I don't want.

I've got postrate cancer. I did a lot of research and found proton radiation treatment. It's the best. It has about a 95% kill rate on the cancer I have. It is not an experimental treatment. It has been around for over twenty years. Some insurance companies pay for it, but others don't. It is about twice as expensive.

Any suggestions on what to do? I can't wait months and months to hagle with them. I can file an appeal and then wait 60 days for them to get back to me. I talked to two insurance reps. yesterday who said it is almost a sure thing to be denied again. What a nightmare!

[steve1 5]

I'd encourage anyone who anticipates getting Prostate cancer to read the book...."You Can Beat Prostate Cancer", by Robert J. Marckini. It's a comprehensive book that looks at all the present day cancer treatments.

This would also be a good time to ask your insurance company if they will cover the treatment you want. If not drop them like a hot rock.

One in six men will eventually get this cancer.

[Bertt 0]

One thing you might try is to talk to your Dr. and see how willing he is to help you jump through the insurance company's hoops. Ask him if he knows of other doctors who have dealt with that company successfully. Sometimes the amount of documentation and persistence the insurance company gets from your doctor will help them change their mind.

You don't have to outrun the bear.

[steve1 5]

We've got an apt. with a Dr. at Loma Linda next week. I'm hoping he will write a letter and give me some help fighting the insurance company. It may be a long flight for nothing, but I'm not willing to quit on this.

There seems to be a big war waging between old school treatments and newer technology. The insurance companies latch onto any study that says an old school, (cheaper) treatment is just as good. They sent one study today stating that traditional radiation treatment is just as good as Proton radiation, at half the cost. Believe me these people are educated and slick.

There's all kinds of research out there that proves about anything you want. I'm going to need help fighting these "Ding Dongs". Insurance companies have teams of lawyers who make a living out of chewing up people in need of better treatment. I'm not very optimistic that I'm going to win on this!

[mpohl 1]

Well, if you are hoping for a white knight in shining armor. Hope on and die! I eventually transferred my cancer care to Europe after loosing group insurance here in the US.

Of course, I was lucky in that I had and have comprehensive health insurance in "socialist" Europe. So, a CT that routinely runs $5,000 here in the US, cost me $0 (or Euro) in Europe. And the interpretation was MUCH MUCH more thorough/ also.

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We've got an apt. with a Dr. at Loma Linda next week. I'm hoping he will write a letter and give me some help fighting the insurance company. It may be a long flight for nothing, but I'm not willing to quit on this.

There seems to be a big war waging between old school treatments and newer technology. The insurance companies latch onto any study that says an old school, (cheaper) treatment is just as good. They sent one study today stating that traditional radiation treatment is just as good as Proton radiation, at half the cost. Believe me these people are educated and slick.

There's all kinds of research out there that proves about anything you want. I'm going to need help fighting these "Ding Dongs". Insurance companies have teams of lawyers who make a living out of chewing up people in need of better treatment. I'm not very optimistic that I'm going to win on this!

[mpohl 1]

Probably the most advanced facility of its kind is the Heidelberg Ion-Therapy Center: http://www.klinikum.uni-heidelberg.de/About-us.124447.0.html?&L=1

Out-of-pocket cost to you if you were insured in the EU, probably $0!!! As a medical tourist, you can probably engage for $25k! Still not too bad, given the fees here in the US.

P.S.: Imagine. All that, at $0 co-payment, deductible, nada.
Right out of Star Trek. Your's if you need it...!
http://www.klinikum.uni-heidelberg.de/fileadmin/pano/HIT_Behandlungsraum/Behandlungsraum.html

[steve1 5]

I'm finding out that one big lever in all of this is the fact that I work for a large school district. We pay this insurance company something like three million, a year. Everyone in my school is pissed about the run around I'm getting. In their efforts to save money, this insurance company is going to lose big, if they continue to deny payment. I think our school is ready to drop this insurance company like a hot rock......

I received a letter from the head of this insurance company the other day. It had about three inches of butter all over it, saying how concerned he was. Then he attached an opinion article stating how the treatment I want is not any better than old school treatments, yet it costs a lot more. That letter not only went to me, but to the president of our state union (MEA).

So, I wrote him back stating how I thought his attached article was B.S., I also sent that to the president of the union. I hate playing games like this, but what else can you do. My appeal process is still underway. I'm starting to feel more optimistic.....

[mpohl 1]

I wish you the best of luck but do not share your optimism.

If I were the insurance rep, I'd take the decision maker of your school district out to a very nice lunch or dinner (escorts are optional). Would stress the long-standing history and beneficial relationship that we have enjoyed as a company and district. And that we (the insurance company) will educate the patient, and have only the insured best interest in mind.

Who do you think your rep will support? The insurance company can wait it out. Question is: can you?!

Sorry if that sounds cynical. But it is how corporate America works. And you are making a possibly fatal mistake if not realizing this.

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I'm finding out that one big lever in all of this is the fact that I work for a large school district. We pay this insurance company something like three million, a year. Everyone in my school is pissed about the run around I'm getting. In their efforts to save money, this insurance company is going to lose big, if they continue to deny payment. I think our school is ready to drop this insurance company like a hot rock......

I received a letter from the head of this insurance company the other day. It had about three inches of butter all over it, saying how concerned he was. Then he attached an opinion article stating how the treatment I want is not any better than old school treatments, yet it costs a lot more. That letter not only went to me, but to the president of our state union (MEA).

So, I wrote him back stating how I thought his attached article was B.S., I also sent that to the president of the union. I hate playing games like this, but what else can you do. My appeal process is still underway. I'm starting to feel more optimistic.....

[steve1 5]

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I wish you the best of luck but do not share your optimism.

If I were the insurance rep, I'd take the decision maker of your school district out to a very nice lunch or dinner (escorts are optional). Would stress the long-standing history and beneficial relationship that we have enjoyed as a company and district. And that we (the insurance company) will educate the patient, and have only the insured best interest in mind.

Who do you think your rep will support? The insurance company can wait it out. Question is: can you?!

reply]

Our school staff is the decision maker in all this. It isn't our administration. If the staff decides to give this cheapskate insurance company the boot, that is what will happen. I think I'm doing the right thing, by getting them riled up....