Ask Wendell: Squeak long and loud with health insurers

Introduction

Deb Richter knows from years of experience that you can’t take “no” as a final answer from your health insurer. You’ve got to fight back.

As a doctor, Richter has gone to bat for many patients after they received denial notices from their insurance companies for care she knew they needed. I wrote about her advocacy for both patients and for a single payer system in Vermont last May.

Now Richter has a new patient she has to stick up for: herself. She recently learned she has cancer, and is discovering that, like many other Americans with life-threatening illnesses, she has to battle her insurer as well as her disease. And she is learning that even doctors have no immunity from the practices insurance companies engage in every day to avoid paying claims.

Last week I wrote about the importance of being a squeaky wheel when your insurer has decided it doesn’t want to pay for expensive treatment, even if your doctor believes your life might depend on it. I noted that most insurance firms have special departments to deal exclusively with what they refer to as “high profile” cases. Squeak loud and long, if necessary. You’re more likely to get the grease. Richter has every intention of being designated “high profile.”

Dear Wendell:

I received a letter from my insurance company stating that they are investigating whether my breast cancer is a pre-existing condition. Mind you, my mammogram one year ago was completely normal. Even when they went back and looked at it again this year and compared it to the positive one I just got, they stated there was no evidence of malignant changes on last year’s mammogram.

I am newly insured with this company (MVP in Vermont), starting March 21, 2011. Ironically enough I was uninsured for two months when my employer at the time neglected to pay the premium. Since there was a gap in my coverage, I think they can use the pre-existing condition clause. Is that right?

My main worry here is that even though I had no clinical evidence of cancer one year ago, it is well known that cancer is present for years before it is diagnosed. Can the insurer use that as their reasoning for not paying claims on a newly diagnosed cancer and claim it is a pre-existing condition?

I have every intention of using this example publicly, Wendell. (Sen.) Bernie Sanders (I-Vt.) is aware and is willing to take them on, too. I feel like Dirty Harry. Make my day.

Deb

Dear Deb:

There are many excuses insurers use to avoid paying claims. Most have employees who do nothing but search for an excuse to deny coverage when someone gets diagnosed with an illness that will require costly treatment. Some of those employees even get bonuses for finding reasons to cancel policyholders’ coverage when they get sick.

Even though you had no control over the missed premium payments—and likely were not even aware until after the fact that you were uninsured for two months—your insurer could possibly claim you do not meet its criteria for covering care related to a pre-existing condition. Some insurers will not pay for such care during the first six or 12 months of enrollment.

Insurers have also been known to scour a patient’s medical records looking for evidence that an illness was pre-existing—even if the patient had no knowledge of it. Even President Obama’s mother found this to be the case. Her insurer refused to pay the disability claims she had filed when she developed cancer because one of her doctors had made a note on her chart that a growth she detected might become malignant. The doctor never mentioned it to the president’s mother (this was before he got into politics), but it didn’t go unnoticed by her insurer. She was still fighting with the company when she died.

If Sen. Sanders is willing to write a letter or make a call on your behalf, by all means ask him to do so. And be sure to tell MVP you have alerted the senator. That will almost assuredly give your case high-profile status. There is a good chance MVP will quickly end its investigation and pay for your care.

Postscript: Dr. Richter emailed me last week with the news that MVP has agreed to cover her care.

“Well, it worked,” she wrote. “I called them and intimated that I had no intention of getting treatment until they agreed to pay for my care and that would be tantamount to their being negligent. I also mentioned that Bernie Sanders was ready to step in, and did they really want to go that route? Within two hours they got back to me stating they were going to pay every bill related to my care. Hmmm. No gun needed.”