Big Insurance Problem

[wendysig]

Hi Wayne,
Hope you get the green light from the hemotologist.  Let me know what happens.

Wendy

[leapyrtwins]

Wayne -

I've been wondering too if your surgery is on for Thursday.

Hope everything has been straightened out.

Jan

[wcrimi]

I am having my surgery tomorrow 11/6/2008 at Mt. Sinai Hospital in NY ay 8:00 AM.

I didn't find out until late this afternoon when the blood test results finally came in.

Wish me luck.   

[Jim Scott]

Wayne:

Thanks for the update.  Not much time to worry, is there?  This might be a good thing.  In any case, you have my hopes and prayers for a successful, trouble-free surgery and a smooth recovery.  Post when you can.

Jim

[leapyrtwins]

Good luck, Wayne.

See you as a postie 

Jan

[wcrimi]

I wanted to update this thread because I may have gotten some good news today that can help others down the line.

I wound up paying Dr. Post out of pocket for my surgery, but I continued fighting Aetna all these months until all my appeals were exhausted. I even had letters from Dr. Post, Dr. Smouha, and Dr Etra (my ENT) on my behalf.  When Atena rejected every last appeal, I called the NYS Insurance Dept. I forwarded all my documention and letters to them. I was told today that Aetna has reversed their opinion and I will be compensated. They are going to consider Dr. Post as part of a team (or something like that) with Dr Smouha who is in my plan. I am probably unlikely to get the full amount, but at this point anything I get is a plus because I was already convinced I had lost and only followed through because I felt I deserved something. I wasn't asking for full compensation. I was only asking for what they would have been willing to pay an in plan doctor. I felt I deserved some extra flexibity because of the type of surgery,  my good chances of hearing retention, and my need for hearing to do my job. 

When I find out what I am going to get, I'll let everyone know.

The good news is that it's not impossible to win one of these appeals if you do all the work and make a good case.

Wayne

[sgerrard]

Hey, hey, that's a great success story, Wayne! As you say, it is not impossible, and dogged persistence can pay off in the end. Nice work!

Steve

[suboo73]

Wayne,  Hi!   Thank you so much for posting this update!  I have been thru ins. company reviews (when my daughter had a car accident), but never had to go to the State level (and really don't know how.)  But if i ever need to, i will learn how!
This information is good to know!
Ditto what Steve said!

I think when you have paid all the insurance premiums and have a more unusual condition, the ins. can 'bend, alittle more!

Take care,
Sue

[Dawn]

HI WAyne,

That is awesome news.  I have been on the phone all morning with insurance company trying to figure out how I'm going to pay for all this.  I've seen Dr. Selesnick, Steig and Dr. Post so far and all are out of network....as for the surgery which I'd like to get done who knows how much I'm going to be in debt for. 

My insurance company is GHI and BC/BS but none of the doctors that i'm even interested in are in this plan.  I don't want to go to any doc to perform Brain surgery.  My hearing is 100% right now and they are recommending the Mid Fossa and say I should have 60-75% hearing preservation.  Problem Dr. Post does not perform this procedure, Not sure about Selesnick but either way he is out of network too.  I don't know what to do? So your news about fighting it and at least getting some covered is very encouraging.  Please keep me updated.

FRUSTRATED AND CONFUSED!!!!!

[Jim Scott]

Wayne ~

Congratulations on your victory...and, make no mistake, it really is a victory.

I've found that appealing to the state insurance commissioner when your insurance company 'stonewalls' your seemingly legitimate claim can have a very positive effect on subsequent claim payment decisions by the company.  My wife and I have been down this road, too.  The reaction from the insurance company is usually rapid but they never admit they were wrong.  No matter, as long as the bills get paid.  Even if you don't receive 100% of what you've laid out in payments, you'll certainly get more than you would have had you simply shrugged and 'walked away'. 

Your case is a credible lesson to others in similar situations.  Prepare, know your facts (the policy limitations and exclusions) and be tenacious .  You, too, can be victorious over the parsimonious insurance company.   

Jim

[wcrimi]

Dawn,

I don't the know the specifics of GHI, but I exhausted all my appeals both before and after surgery at Aetna before I went to the state insurance board.

I basically made the case that I wanted to go out of network because DR. Post gave me a better chance of hearing preservation than the IN PLAN alternative they suggested and hearing was important to my job. I also noted Dr. Post's vast experience with AN surgery relative to most other doctors that could do the procedure, the fact that many of the "in plan" doctors worked with other surgeons that were not in plan so I would be right back where I started if I went to an alternative (I also consulted with DR. Galfinos at NYU who is in my plan, but his partner Dr. Roland was not), and told them that Dr. Smouha often worked Dr Post as a team and Dr. Smouha was IN PLAN. I even had letters from my ENT, Dr. Post and Dr. Smouha saying all the same things. They rejected me at every point.

The state insurance guy was hardly interested in all the letters I wrote, my hearing test results, MRI reports or my whole story. All he wanted was copies of the doctor's letters and everything that Aetna had ever sent to me rejecting my appeals. I guess he was a lot more powerful than I am because they changed their tune quickly.  I did a lot of work to win this fight. It was very stressful before the surgery and I borrowed money to pay Dr. Post that I will now hopefully be able to pay back quickly. But I also have to thank all my doctors for giving me letters to support my cause. That apparently is the key.

Feel free to ask me any questions as you move through the process and don't be afraid to ask an out of network doctor for a small break in the fee if money is an issue (and it is for almost everyone). Dr. Post was very good about that and Mt Sinai was willing to work out an extended playment plan if I couldn't come up with the cash. I'm sure there are other doctors like that.

Also, check is Dr. Galfinos is in you plan. He seemed like a terrific guy also. 

You can contact me privately if you would like.

Wayne