1974 ERISA Law

I've been thinking a lot about the 1974 ERISA (Employee Retirement Income Securities Act) law since I received my denial letter from the insurance company last week. (Which by the way,  yesterday I received the returned signature cards showing they received the certified letters for both the appeal and documents request).

The reason I've been thinking about ERISA is because it was noted in my denial letter and according to my research this law has been exploited by many insurance companies in order to no longer honor their obligations to policy holders. 

I found two articles/briefs that got me thinking about my own experience. Both are worth a read if you have some time. Specifically the second one that discusses exactly how this law is used against patients in insurance cases.

http://www.patientadvocate.org/index.php?p=443 

and

http://www.patientadvocate.org/pdf/ERISA.pdf

One thing I found surprising is in my own denial letter. The insurance company informed me I had 180 days to appeal the denial. However, with ERISA I really only have 60 days or a judge could throw out any future lawsuit regarding the case. 

I have a solid connection to a law firm willing to represent me, but I wanted to fully explore my options so I contacted a local firm that specializes in ERISA law. When I queried them I received a response back that this specific firm only represents the insurance companies with their knowledge of ERISA, not the patients. Of course large companies with large legal budgets are where the real money is, so from a financial perspective I understand that law firm's decision. I'm saddened though that this firm would use its knowledge to support companies known to abuse this law. 

The loopholes this law offers, I'm sure were unforeseen in 1974. However, over the years companies have discovered new exploitation methods using older laws. It's sad... and we're clearly at a point when these laws need to be changed. 

When I spoke to the insurance person who sent me the denial letter (before the denial was ever sent). He informed me this was "nothing personal"-- it was simply business. 

I would argue, "business" set up on loopholes and a year end bonus structure that encourages vilifying an honest policy holder, is very personal. Making up false claims about another human being in order to receive a year end bonus for saving the company money, is very personal. Trying to use intimidation tactics to harass a client because you know that client is not allowed a jury trial under ERISA, and you will never have to answer for that harassment, is very personal.

I am not a moral authority. I'm just an average human being whose integrity is being attacked by a company for the sake of money. And I'm wondering when the collective "we", as employees, stopped listening to our conscience and instead put all our trust in company policies meant to harm clients. 

I encourage anyone reading this to fully educate yourself on ERISA so you will have some basic knowledge should it ever be used as a tool against you. 

Denial Letters Without Using Facts

Earlier this year I posted a blog with a denial letter I received stating I was denied coverage, because.
http://themalformationofhealthcare.blogspot.com/2012/08/denial-because.html

No, I didn't forget to finish the above sentence. The denial letter I received said I was denied coverage "because." No further explanation.

It turned out the reason I received the denial was because of an inter-insurance-company problem having nothing to do with me. So when the insurance company didn't pay my claim, they had no reason for why it was denied, and therefore left the section blank. Leaving me to panic, call them, and wait until they cleared up their error and pay the invoice prior to me ending up in collections for something that should have been covered through insurance.

Ready for something to top not giving a reason for a denial.....

Drum Roll Please.....

Yesterday, the insurance policy I have held since I had to stop working due to my arteriovenous malformation and chronic myelogenous leukemia sent me a letter listing off several reasons why they have decided to stop honoring their obligation to my claim. They included not hearing back from my doctor (although my doctors name was spelled completely incorrectly and I can only wonder if she even received the documents she was asked to fill out). Partial information from a report done by a doctor who in a video taped interview stated he did not treat either condition I have. Video taped surveillance showing me go into a local business for 3 hours (without mentioning it was a dental office)...And the piece de resistance....

 because my oncologist informed the company that I was in complete remission from AML.

You can imagine my relief to hear I was in complete remission from a condition I was never diagnosed with.

Here's the portion of the letter:

Yes, this denial letter stooped so low as to deny my claim using completely false information.

AML is Acute Myeloid Leukemia. It is a really terrible blood cancer that is difficult to control. I have known two young adults who have battled this disease. One survived it and one did not.  AML is treated with aggressive traditional chemotherapy and often a bone marrow transplant.

I have Chronic Myelogenous Leukemia-- a completely separate condition that currently has no proven "cure" outside of a bone marrow transplant. Fortunately for me, as long as I take a daily chemotherapy pill my chronic leukemia is kept at bay in the body. It is not a traditional "remission" as suggested by this letter. It is a conditional cytogenetic response to a daily chemotherapy drug.

I sent in the appeal letter today correcting their misinformation and requesting my policy to be reinstated. Should this company deny the claim a second time my only recourse is to hire an attorney.

Thanksgiving for Non-Profit Groups!

Thanksgiving is this week and I'd like to take a moment to thank all of the advocacy groups out there dedicated to helping those struggling with health care.

Groups like

The Patient Advocate Foundation:  http://www.patientadvocate.org/about.php?p=901 
that has an online web-chat to answer specific questions a patient may have regarding insurance access, job retention, and medical debt.

P.S.I/ Patient Services Incorporated: https://www.patientservicesinc.org/how-we-help/default.aspx
that offers co-pay assistance to some patients on extremely expensive medications.

Sy's Fund: http://sysfund.org/
that encourages young adults battling cancer to also pursue their artistic/ life goals outside of their health  battle.



There are so many wonderful organizations out there that I would be remiss to try and name them all. However, I am happy to update this post with additional references if you simply comment below with the name of the organization and what it focuses on.



Blessings to you and yours during this holiday season!

Basic Tips on Working With Health Insurance

As many of you are aware The Malformation of Health Care book just became available on Amazon.com

 http://www.amazon.com/dp/B009V37CXU

In the book I detail several tips and tricks on how to navigate through our very complex and often times confusing health care system.

Today I want to take you inside the book and give you some basics of where to begin. Although some of these may seem obvious, they are often things that are overlooked when thrown into a stressful situation.

Checklist for Health-Care Rights and Service

Know your benefits: Get a printout from your insurer and know your deductible and out-of- pocket maximum. This way, you can track what you are responsible for. Be an educated consumer.

Ask for a case manager. This is a contact person within your insurance company who will know your case and be of real benefit to you if it is a complicated one. If your insurance company says you can't have a case manager, keep asking. Once they see all the claims coming in, most likely the company will change its mind.

Keep all of your insurance claims and bills/booklets, which you can usually do online. Keeping hard copies is probably a good idea, just in case your computer or backup drive dies.

Appoint an organized family member/friend to help you with all of this because it can be overwhelming␣especially if you're sick.

Reach out to a hospital social worker or to local nonprofit organizations (such as the Cancer Legal Resource Center, the Leukemia & Lymphoma Society, etc.) for ongoing help or support. They will know of good resources to help you if you're in trouble and can save you a lot of legwork.

Write down the name of anyone you speak with at your insurance company every time you contact your provider or your provider contacts you. Make sure you record the full name, date, and a detailed synopsis of the conversation.

Follow up!

If you are denied coverage, do not be afraid to appeal. Jump through all the hoops the insurance company asks of you, and document everything. If, at the end of the appeals process, you need an attorney, you will have something to give him or her.

Learn all you can about your condition. A lot of times, insurance company workers know little about your condition.

Check with your insurance company about its fertility policies. I include this advice because many young adults are diagnosed with serious illnesses that may require heavy medications and treatments. At the point of diagnosis, someone who is in their late teens may not be thinking about future plans for a family.

Have a relationship of open communication with your doctors, who can help to advocate for you. Know that there is creative coding for blood tests and other procedures you may require to facilitate your health. A test that might not be covered if coded in one particular way may pass muster with your insurance company if coded in another way.

Know your out-of-network benefits! Sometimes you may be referred to specialists who may not be in your insurance company's network␣ What is the percentage and how does your out-of- network benefit work with your deductible? Do any of the company's in -network doctors offer the same care as the out-of-network specialist to whom you have been referred? If not, most policies have provisions to cover out-of-network providers when no in-network doctor has the same capability.

Try to connect all of your doctors, so that each knows about your health in relation to the other physicians providing your care. If you can start a group dialogue among your doctors, your care will be better.

The Malformation of Health Care (Chapter 25) Copyright Erin Havel 2012

Secret Video Surveillance by Insurance Companies

I would like to start out by saying people who scam systems that are set in place to help others really stink. I know these people exist, and I know they are the reason companies running services to help others are suspicious of everyone.

HOWEVER, I am not one of those people. After the first time the long term disability company secretly video taped me walking my dogs, came into my home, and barraged me with questions for 3 hours, I thought I had established that fact. They sent me paperwork, after all, saying I was indeed not scamming the system.

After that experience, (3 years ago now) thanks to all the medication I was on, I became paranoid that I was being watched at all times and wound up a recluse for about a year. I was depressed from being sick anyway, and with the added anxiety of that situation, and heavy doses of medications--I didn't have a chance at handling the situation well at all.

So you can imagine my stress level today when they called again asking for another "meeting" to "discuss" my claim.

I have leukemia, and I'm under doctors supervision for a vascular malformation.

My doctor and I fill out the forms the disability company asks for every 6 months. In the last paperwork we filled out, my doctor (rightly so) said she felt I was improving. I am. My vascular malformation is being watched with MRI's instead of actively forcing me into hospitalizations once every month.

The leukemia is chronic, however, and while I am tolerating the medication as well as can be expected... I am on a daily chemotherapy pill... and I will be for the rest of my life... unless researchers discover a cure. This comes with its own set of side effects-memory loss and retention issues, extreme fatigue, weight gain, edema, nausea, vision problems, muscle cramps, bone pain, (and entirely too many others to mention)---take your pick of the laundry list.... it's chemotherapy without an "end" date.

So there's that.

Then let's talk about the cost of that particular drug. $6,700.00 (i'll round down) per month. No, there's no stress there about making sure I'm covered for that... (sarcasm)

So here comes this company that gives me about $100 a month to help me get by (thanks to a policy I had at my last job) doing secret video surveillance on me yet again.

I asked the guy when he insisted on meeting in my home instead of a public place (because he didn't want me to feel uncomfortable discussing "personal information") if this was along the same lines as the last interrogation. I explained to him how the medications mixed with the anxiety that situation caused me put me into a deep depression where I didn't leave my house for a year... and if he was going to show me a video of me walking my dog as proof of why I no longer qualify for my policy... I would need to have an additional person with me because I emotionally can not handle going through that again.

He said it was indeed similar and he was shocked to hear I'd been through it before. He would check with his supervisor to see if this was a mistake.

How walking my dogs incriminates me, I'm not quite sure.... does leukemia mean a person isn't allowed to walk for 15 minutes a day when they're feeling able? to try and maintain some semblance of health outside of the disease?

I wonder if they read this blog... and if they think the hour I spend writing it demonstrates my ability to teach science to 6th graders 5 days a week for 8 hours a day.

My current question is should I have an attorney with me at this meeting? And---at what point does this become harassment?

You're probably thinking "Erin, it's a hundred dollars a month---just let it go so you don't have to deal with these jerks." My immediate reaction is to agree. Then the social justice aspect raises up in my stomach and says "If you roll over and play dead, they'll hurt other people who aren't as lucky to have support as you are."

So there's my current health care dilemma and stress.

I'm obviously not the only person this has happened to.... see below:

http://abcnews.go.com/GMA/TheLaw/claims-disabled-people-hartford-stopped-insurance-benefits-surveillance/story?id=10301625#.Tztabpj-RSU

http://www.diattorney.com/hartford-relies-on-video-surveillance-of-the-insured-to-deny-disability-benefits/

http://www.milwaukeeemploymentlawattorneys.com/2009/06/the-hartford-violated-erisa-by-failing-to-identify-alternative-jobs-for-claimant.shtml

http://www.diattorney.com/hartford-continues-to-use-video-surveillance-to-wrongfully-deny-long-term-disability-claims/

http://www.badfaithinsurance.org/reference/General/1418a.htm