I had a stroke / then a PFO Closure / Then my evil Insurance Copamny denied payment on the $100,000

New Topic Post Reply Printable Version
[ << Previous Thread | Next Thread >> ]

Carlos512
New Member


Date Joined Nov 2010
Total Posts : 6
   Posted 11/8/2010 8:11 PM (GMT -7)   
My name is Charles Piper. I have no ulterior motives, no massive legal team, no nothing. I am simply a computer programmer for the state of Texas and have been for 25 years. I have a family of 2 daughters (5/10 yrs) and a female Corgi named Marley after the musical genius. I live in a big metro area of about 1 million people. There are a lot of brilliant doctors here who know what the best medical care should be, particularly the very specialists who devised my game plan.

On June 2, 2010 at the age of 49 I had an ischemic stroke that hit my brain in 3 places. By miracle I am OK, more or less. I have been in great condition all my life and have always been within 5 pounds of my high school weight of 155. I have always worked out 7 days a week, grew up playing competitive tennis. Still work out daily. I was in the city's biggest hospital for 5 days. They did every test I think ever invented, and after the 2nd day, a heart bubble exam. about 30 minutes after that test the heart specialist came in and, I quote, said "Do you know who Ted Bruschi is? You had exactly what he had.". No exact stroke cause with no stroke risk factors of any kind to battle.

The next 6 weeks I spent going over what to do with my primary care physician, 3 heart specialists, and 3 neurologists, not to mention a lot of other doctor opinions. After multiple referrals letters from the Insurance company, preliminary tests, several specialist visits, I got the heart operation at the city's biggest hospital on July 7, 2010 to close my PFO opening. The doctors presented that as a Michael Jordan-esque slam dunk.

Then the dreaded hell arrived a month ago. The evil component to all this (aside from the actual friggin condition), my Insurance provider for me and over 200,000 other state employees, has denied paying the $100,000 claim by labeling it experimental. A room full of "suits & ties" are telling the medical profession here they were wrong. THAT ITSELF IS BIZARRE! I have one shot of an appeal with the state agency in charge, so I win there or else it really gets weird for me.

I am "shotgunning" to anyone & everyone to see if anybody out there cares and has any tips, advice, internet links, or insights that would help me present my case better. That happens probably around January 2011. I need to focus on why this is not experimental.

I don't have a spare $100,000 laying around. I have two daughters who will eventually need braces and college, not being victimized by Insurance robbery. Any help delivered by anyone in any fashion would be greatly appreciated.

Later and thanks
<Edit>  I have removed your email from the open forum and strongly suggest that you put it is your profile to protect you from being spammed.
 
Thank you and I will respond to your post today. 
Kitt

Post Edited By Moderator (stkitt) : 11/9/2010 7:43:16 AM (GMT-7)


stkitt
Forum Moderator


Date Joined Apr 2007
Total Posts : 32602
   Posted 11/9/2010 1:35 PM (GMT -7)   
Hello Charles and I am so sorry your having this problem with the insurance company.  I have read 100s of posts from members who have had the surgery and no problems with the insurance companies.
 
You may want to consider outside help in getting this resolved as the bill is tremendous.
Request your state Department of Insurance to help you – this is free. The amount  these departments can help varies from state to state. But some states with strong departments (California, New York, Illinois) will mediate your dispute.

Find a professional arbitrator or higher a lawyer. 

Resources for Additional Information

Consumer Coalition for Quality Health Care
1275 K St. NW, Ste. 602
Washington, DC 20005
Phone: 202-789-3606
Web site: http://www.consumers.org

Center for Patient Advocacy
1350 Beverly Rd., Ste 108
McLean, VA 22101
Phone: 800-846-7444 or 703-748-0400
Web site: http://www.patientadvocacy.org

Consumers for Quality Care
1750 Ocean Park Ave., Ste. 200
Santa Monica, CA 90405
Phone: 310-392-0522
Web site: http://www.consumerwatchdog.org

As I read your story it makes me fear that someday my insurance company could to this very same thing to me. 

I wish you the very best,

Kitt


~~Kitt~~
Moderator: Anxiety/Panic, Osteoarthritis, GERD/Heartburn and Heart/Cardiovascular Disease.
www.healingwell.com

"If you can't change the world, change your world"

stillsmiling
New Member


Date Joined Nov 2010
Total Posts : 8
   Posted 11/9/2010 4:35 PM (GMT -7)   
Hi Carlos, I am sorry, and shocked, that this can happen. Sadly you are not alone in this battle with insurance companies. (Being in the UK means I wont go through this. The NHS does have some good points!)

I found this artical, Clinical outcomes of patent foramen ovale closure for paradoxical emboli without echocardiographic guidance.

http://ukpmc.ac.uk/abstract/MED/15274165

This just takes you to the abstract but it may be worth subscibing to if you are to collect enough data to prove your case. If you click on the citations tab it gives you links to many other studies. This is a 2004 paper and I am sure there are more recent ones. Good luck - you do this for all of us.
x stillsmiling

charlie.ungashick
New Member


Date Joined Nov 2010
Total Posts : 2
   Posted 11/9/2010 6:14 PM (GMT -7)   
Hi Charles,

My name is Charles too and I as a healthy 39 year old with a TIA and PFO, we're in the same boat. As a result of my own personal experience (very similar to what you just went through), I joined forces with a few other PFO patients to form a non-profit group called PFO Research Foundation. It's a patient for-patient group aimed at not only helping people like yourself but also to advance the state of the knowledge and patient care around PFO treatment. Just last September we hosted our first PFO conference, catering to over 200 interventional cardiologists, neurologists and industry players to discuss ways to create consistency for providers and patients alike around what is today a very frustrating area of medicine.


Unfortunately PFO closure isn't currently approved byt the FDA. That results in broad discretion by insurance companies to set their own payment policies. Very fortunately, my closure in March 2010 was covered by my insurance company. I've heard from several others that they encountered denials, as you have. Patients also encounter a variety of different opinions about how best to treat a PFO - blood thinners, closure, do nothing.

I am so thankful that (like me) your TIA didn't result in more damage and that your PFO was closed.

Best to you!
Charlie
 
<Edit>  Self-serving links are not allowed in the forums.  This means any links to sites that you own and may be trying to promote or advertise by posting links in the forums.  You are listed as an administrator for one of the sites.  The first site you may submit to our administrator to see if it qualifies to be included in our resources.

Post Edited By Moderator (stkitt) : 11/10/2010 5:07:51 PM (GMT-7)


stkitt
Forum Moderator


Date Joined Apr 2007
Total Posts : 32602
   Posted 11/10/2010 5:09 PM (GMT -7)   
Charlie,
 
Sorry for the edit however to keep you compliant with the rules of the forum I removed your links.
 
Thank you in advance for your understanding.
 
Kitt
~~Kitt~~
Moderator: Anxiety/Panic, Osteoarthritis, GERD/Heartburn and Heart/Cardiovascular Disease.
www.healingwell.com

"If you can't change the world, change your world"

Carlos512
New Member


Date Joined Nov 2010
Total Posts : 6
   Posted 11/10/2010 7:32 PM (GMT -7)   
Thanks for the tips Kitt

I have done a few of the things you suggested and will try the others. The state Insurance board here in Texas is useless. Even the guy I talked to inferred that. That doesn't surprise me, given our political agenda. I found a lawyer essentially through the internet and he seems good, we'll see about that. I hope not to have to use him too much.

For the moment I am trying to win the appeal done with a state agency. I've tried to find simple facts, like how many PFO closure operations have been done in the USA since, say, 2000. You wouldn't believe how difficult that is to discover.

Thus far my impression has been that the entire medical community is disgusted with the Insurance abuse handed down by these greedy jerk offs. I mean, Sick-o by Michale Moore covers it well. Problem seems, though, that this same medical community is great at ranting and utterly pathetic at actively fighting it. Perhaps I'm just a naive fool, but they all seem afraid or disinterestd.

Carlos512
New Member


Date Joined Nov 2010
Total Posts : 6
   Posted 11/10/2010 7:40 PM (GMT -7)   
Hey x stillsmiling

Thanks a ton. That's the type of stuff that could help. I have stumbled upon a few like this and none seem free. I would pay for some if I knew the outcome. I mean, I don't want to spend something like $25.00 only to find out the paper is useless. I found a few that even wanted $500. Yeah, right.

Anyhow, I will be hitting up your link ASAP.

The internet, sites, forums, organizations, etc., are great but they do tend to bypass one of the most stressful components of this health puzzle- when you think you have insurance but then come to find out you don't. Where to start the fight?

In closing, thanks. How about a punchline to end on: the bill they denied has 6 transactions spread out over July 7 and July 8. These jerk offs are paying for 4 of the 6 but not the 2 expensive ones. Not only are they arrogant, they are sadistic.

Later, Carlos.

Carlos512
New Member


Date Joined Nov 2010
Total Posts : 6
   Posted 11/10/2010 7:49 PM (GMT -7)   
Charles, a huge thanks.

I would like to get in touch. Could you please contact me at cpiper512@gmail.com and then from there maybe we could talk via phone. I'm not a email stalker and I don't bite. I just want to win the appeal as I should. What if you're insurance company is the same as mine, for example.

Down the road I want to also help empower people who get abused by their insurance provider, so I would like to be in contact.

You're a fantastic connection and I'd like to hook up. Please respond.

Later, Charles.

Mavica
Regular Member


Date Joined Jun 2008
Total Posts : 407
   Posted 11/15/2010 9:51 PM (GMT -7)   
It's generally accepted that prior to surgeons and hospitals undertaking such procedures that they receive a pre-authorization from the insurance company.  It seems that your team failed to do this, and it's to them I would put this question about payment.  Someone dropped the ball.  I've had prostate cancer surgery and heart stents inserted within the past two years - both procedures at a great expense - and neither was done without the advance approval of the insurance company ... which is the requirement of my policy.  Best wishes for a successful outcome to your situation.
 
 
Age: 61 (58 at diagnosis - June, 2008)
April '08 PSA 4.8 ("free PSA" 7.9), up from 3.5 year prior
June '08 had biopsy, 2 days later told results positive but in less than 1% of sample (Gleason's 3+3=6)
Developed sepsis 2 days post-biopsy, seriously ill in hospital for 3 days
Dr. recommended robotic removal using da Vinci; Surgery 9/10/08
Northwestern Memorial Hospital, Chicago, IL; Dr. Robert Nadler, Urologist/Surgeon
Post-Op Gleason's: 3+3, Tertiary 4; Margins: Free ; Bladder & Urethral: Free
Seminal vesicles: Not involved; Lymphatic/Vascular Invasion: Not involved
Tumor: T2c; location: Bilateral; Volume: 20%; Catheter: Removed 12-days after surgery
Incontinent: Yes (1 to 2 light (woman's style) pad per day)
ED: Combination of Cialis and MUSE (alprostadil) once weekly: started 9-27-08
Returned to work 9-29-08 (18-19 days post-op)
PSA test result, post-op, 10/08: 0.0; 12/08: 0.0; 4/09: 0.0; 9/09: 0.0; 3/10: 0.0; 9/10: 0.0

Carlos512
New Member


Date Joined Nov 2010
Total Posts : 6
   Posted 11/19/2010 9:48 PM (GMT -7)   
Hey Mavica

Thanks for the input.

What you suggest is one of my fall back strategies. I will fight the primary denial of this being experimental head on though because that is evil or worse.

Here is why what you point out is incredibly disgusting to me. It is wrong. It is one of the main reasons our country is hopelessly messed up in regards to the medical arena. What exactly is America? Let me guess, if you don't have insurance you are screwed. If you do have insurance you may very well still be screwed.

So, in my case, let's just assume the biggest hospital in the city called the Insurance maggots and they said my operation was no covered because they- not the darn medical profession- sat in some sorry ass profit incentive room and decided that what I needed was too ***n expensive for their annual profit sheet. So rather than listen to people who are trained to understand the human body and move forward with medicine, they say nope, not gonna allow it, it messes with out profits, so we'll call it experimental. Then they tell me to go stand on the street with a cardboard sign and collect money to get an operation that I need! If not, just sit around and hope all goes well.

Are you kidding me! If it was up to them medicine would still be in the dark ages. Yeah, I know, you're trying to help and all that, and I do appreciate it, but until people revolt aginast that EXACT fu%^%^ logic we're all screwed.

The same passion that started this country several hundred years ago ought to be shoved right up the Insurance Industry's butt. They are filth.

Thanks, Alec or Charles, take your pick.
New Topic Post Reply Printable Version
Forum Information
Currently it is Monday, December 11, 2017 12:54 AM (GMT -7)
There are a total of 2,903,873 posts in 318,693 threads.
View Active Threads


Who's Online
This forum has 158103 registered members. Please welcome our newest member, NonI of two.
195 Guest(s), 4 Registered Member(s) are currently online.  Details
The Dude Abides, jgedlttlpill, testuser1234, NotQuiteAntonio