July 31, 2007
Fighting Your Insurance Company to Stay Alive
From NYTimes.com:
Gordon Hendrickson was sick.
Five years ago, when Mr. Hendrickson was 66, routine blood work found something amiss with his liver. One test led to another, and then to an awful diagnosis: pancreatic cancer, one of the deadliest kinds.
But he was lucky. The cancer was caught early enough that perhaps it could be cured with surgery. He needed a Whipple procedure.
However, there were no experts in his hometown.
Albuquerque’s population was less than half a million, and the entire state of New Mexico had fewer than two million people, not enough to give local surgeons much practice with a relatively uncommon operation.
An experienced surgeon and hospital can significantly increase the odds of survival for people with pancreatic cancer, studies have found. Lower complication rates can also minimize the cost.
Mr. Hendrickson found a cancer center in Houston and an internist he was comfortable with. However his insurance, the Presbyterian Health Plan, refused to cover the procedure in Houston.
Mr. Hendrickson decided that his life was the most important thing so using a credit card to pay the deposit (since he would be having the procedure without insurance) he signed the paperwork and had the surgery.
[The surgery] went well. But he was left with more than $80,000 in medical bills, which Presbyterian Health Plan refused to pay.
Two appeals later and a trip to the state appeals board found Mr. Hendrickson acting as his own lawyer. The insurance company was represented by two lawyers.
Mr. Hendrickson won his case by showing that the five doctors recommened by his insurance company had performed this type of surgery only five times in five years. Presbyterian Health Plan paid the total cost of the surgery.
A spokesman for Presbyterian said the case had led the company to allow more patients to be treated at high-volume centers if there was evidence that the results would be better.
Strange, I thought we knew that going in.