“Don’t give up. Don’t ever give up.”
These words, uttered almost 20 years ago by a gravely ill Jim Valvano at the 1993 ESPYs, form the backdrop for Health Navigaid’s first blog. But this time the story has a happy ending – we recently learned that a dispute that had reached the Illinois Department of Insurance (DOI) has been decided in favor of our client and against the largest health insurer in the State of Illinois.
The hero of this story is our client Dan (name used with his permission), whose indomitable spirit and refusal to accept less than he deserved made this outcome possible. The fundamental issue in this case was the failure of Dan’s PPO to allow him to exercise his contractual right to select a participating surgeon and receive the full financial benefit of using an in-network provider. After pre-approving the medical necessity of his major abdominal surgery, Dan was informed by his health plan that no participating surgeon with the capability of performing the highly specialized procedure he required could be found in their PPO network. Left to fend for himself, with the clock ticking on a pre-surgical situation that could have turned life-threatening at any time, this is what Dan endured over the last 18 months:
- Forced to conduct his own research with no support from his health plan, Dan found a skilled out-of-state surgeon with particular expertise in the procedure he needed. He kept his health plan informed of these developments and received verbal assurances that his surgery would be covered as in-network.
- With no local participating surgeon available to Dan from the largest health insurer in Illinois, Dan was forced to spend approximately $1,000 to travel out-of-state for his surgery.
- He spent 19 days in an out-of-state hospital for his surgery and recovery, and missed almost two months of work.
- Almost five months elapsed before Dan’s health plan adjudicated the claim from his surgeon. The claim was processed incorrectly. Instead of having a modest balance due of approximately $300, Dan was informed by his health plan that he owed $9,000 to his surgeon.
- After trying unsuccessfully to resolve this matter with representatives of his health plan, Dan exercised his internal appeal rights and filed an appeal of the surgical claim determination with his health plan.
- Dan’s surgeon, rightfully due compensation for his services, began to accelerate collection efforts.
- After being advised by health plan representatives to withdraw his appeal because the claim was being reprocessed, Dan withdrew his appeal. The claim never was reprocessed.
- Dan refiled his appeal. This new appeal was denied. The responsibility of his health plan to maintain a provider network with the capability of providing all medically necessary covered benefits was not even acknowledged. Dan’s health plan informed him that he had exhausted his internal appeal rights.
Any of these difficult circumstances would have caused many of us to accept the will of our health insurers and just give up. But Dan is a person of extraordinary fortitude and conviction. In the late Spring of 2013, Dan engaged Health Navigaid, and we became his voice. After trying unsuccessfully to have Dan’s health plan reopen his appeal, Health Navigaid filed a formal complaint with the Illinois DOI in July. While health insurers tend to dislike us, state insurance departments appreciate our expertise and technical soundness in articulating our cases, which makes their jobs that much easier in analyzing member-insurer disputes. Following the favorable determination from the Illinois DOI, the entire $9,000 balance of Dan’s surgical bill will be paid by his health plan.
The two lessons to be learned from Dan’s experience are the power of perseverance and, if you are in the right, it is possible to go toe-to-toe with your health insurer and prevail. Health Navigaid is here for you.
So don’t give up. Don’t ever give up.