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Our $22,000 bill for having Pia

I’m sure most people are borderline sick of hearing anything regarding Health Care. Actually I have been very purposefully silent on this site about this very big and serious struggle we’ve been carrying for the past year. I haven’t even bothered to keep up nearly one bit with any of the Government run health care initiatives taking place in the current political environment. Honestly, I have experienced more than my share of Insurance Woes in the last few years. I’m jaded to the point I don’t even care what the hell they conspire and pass, it’s going to be flawed and not work from the start. That’s because it’s built on the back of a system that’s flawed and nearly nothing works well from the start. Really, I’m not here to preach on this topic, mostly I am pretty a-political, but Health Insurance in general just gets under my skin and rilles me up (for reasons I am about to explain). I haven’t brought any of this up for a few reasons. Reasons that I haven’t been able to given these circumstances, legalities of appeal processes and to protect ourselves in case this issue became a seriously large case. However, if you are close to us, it probably has seemed like often this is the only thing we’ve talked about. Actually, I have gotten pretty frustrated feeling like this whole insurance thing has become such a Sob Story. I can say, it’s over now. It’s over now, with a sigh of relief.

First I need to back up. Like a few years.

So Matt works for himself. And so it goes with working for yourself that you also get to supply yourself with Health Coverage by yourself. I know we aren’t the only people in this boat, many of you can commiserate that it sucks. Premiums are higher. Coverage is inadequate. Two years ago after my second c-section with Tallis, the insurance companies got away with increasing premiums for Individual plans for women who had previous c-sections. We were considered High Risk. Our family premium hit nearly $800 per month for the 4 of us. We just couldn’t afford it. So we dropped the Big Insurance company and signed up for care through the National Association for the Self Employed, being promised with better care at a lower premium cost by the sales person who came to our house. One month and $600 in checks later, we find out the promised coverage would be over $250 a month more expensive than we had signed up for and we, the whole family, were considered high risk because of my c-sections. So we went from the health tier of 20-something, non-smokers to being equivalent risk to people with heart disease and certain types of cancer. Research showed that this was indeed legal, for Individual plans and we would face this issue regardless of the company we were insured by. Plus, the promised coverage was far less than we were sold on. With the deductible we were given we were better off to pay for the health care we actually used out of pocket and save thousands of dollars each year. So we dropped that insurance, and it took another 30 days to get them to return our money. That alone was like pulling teeth. We made the decision at that point to sign Matt and the girls up for Catastrophic coverage. The three of them was only about $150 a month, as I was obviously the expensive one to Insure. I went back on my own plan with the Big Insurance Company, but with the NASE fiasco between November and December and having to re-apply for coverage, I had to wait the entire month of January until I had coverage at nearly twice the cost of Matt and the girls. Now that time span is actually important, because that is now considered a lapse in coverage greater than 63 days, which puts me in subject to Preexisting Condition Waiting Periods.

According to State Law and the language derived from it in the benefit booklet, a Preexisting Condition is one that “..medical advice was given, for which a health care provider recommended or provided treatment, or for which a prudent layperson would have sought advice or treatment, in the six months prior to the effective date of the plan.” The basis behind the law is obviously to prevent persons who have or know about conditions to obtain insurance to cover medical costs for those conditions. But at what point do you start splitting hairs enough over the grey language of what exactly defines a ‘prudent layperson’ and how do you pass judgement on when, why and how they should have sought treatment? In my case, this is unfortunately what it boiled down to.

As I documented on this blog, I didn’t find out I was pregnant with Pia until I was over 14 weeks along. Even my doctor, and another OB she consulted with, were convinced, from my medical testing, that I was having a miscarriage. When I went in for the ultrasound, I thought I was then going to be admitted for a D&C. When I found out I was pregnant, I was well into the first month of my coverage with the Big Insurance Company. When I first made the appointment and went into my doctor, it was after the magical effective date of coverage and for a condition unrelated to pregnancy. I even got a negative home pregnancy test. The remainder of the pregnancy continued as normal. Pia was born via C-section on August 13th, 2008. A month later, the billing was getting sorted out. My insurance paid for the surgery, anesthesia, and hospital stay. A month after that, just about a year ago now, they revoked payment for those three bills, citing my pregnancy as a ‘Preexisting Condition.’ If you read the law as we did, then it would be obvious that since I hadn’t been diagnosed until after my effective date of coverage, then therefore it couldn’t be a preexisting condition. The Insurance didn’t see it that way. The only thing we could do was Appeal.

We gathered doctors notes, chart notes, lab tests. We wrote a long letter explaining the circumstances. A few months later we were fed a standardized one page statement that the denial was upheld. At this point, it became obvious it was us, the little fish, versus the Big Bad deep-pocketed Insurance company who didn’t want to give up any money it didn’t have to. As we proceeded into the Second Level Appeal, we did a lot more homework. We hired a lawyer (a really awesome one at that, who supported us and backed us up every step of the process). We hired my doctor to draft a letter. We spent countless long nights writing supporting documentation covering every possible angle of our arguments behind how I couldn’t have known I was pregnant. We solicited friends to proof read our statements. We had countless people praying for us. We were able to actually go in and present to the Internal Appeal Panel in person (well, and phone conference). I realized at that point I might need prescription strength deodorant (it likely wouldn’t have been covered, though).

A month later we get another denial letter. Their reasoning for the upholding of the denial had obvious implications on the legality of other people, further allowing the Big Insurance Company to twist the language of the law and deny coverage for which people would otherwise be entitled to. They stated that because I had said my ENTIRE FAMILY had the stomach flu in January that was enough grounds to call the flu pregnancy symptoms. Further, that because I took a pregnancy test and got a NEGATIVE result, just the fact that I took the test suggests I considered pregnancy and therefore should have sought treatment for pregnancy. That is like saying (for a guy) that someone who gets a prostate screening test done and then less than a month later is diagnose with prostate cancer, that just the simple act of RULING OUT a condition is enough to deny coverage. It’s saying that the Insurance considers it enough grounds to deny coverage based on the person even CONSIDERING the POSSIBILITY of  a condition. What it comes down to, is that the Big Insurance Company is making a bold statement that it will deny coverage for conditions that the insured was not reasonably aware of or did not know about, which is in contradiction with the protection the law is there to provide. For the Company to make this claim is absolutely absurd and leaves me with very little faith in the system as a whole if it truly believes it can interpret the law in this twisted way and get away with it.

Meanwhile, we were also dealing with the billing end of this with our Doctors, trying to keep payments at bay, negotiate the rates the insurance had already paid, and prevent collections from happening. The sum total for the bills was near $22K, payment negotiations was coming out to nearly $2100 per month to pay this amount off. For a family of 5, single income who relies on State Food subsidies to buy groceries and has no savings, you can bet this was dauntingly impossible. I have no doubt God somehow, someway would have provided for us. I so far better understand how people drown in medical debt. We have had our fair share in the past too, and I know in the greater scheme of thinks, $20K is not that much. It would have meant some very serious changes in addition to what we have already slimmed down with work being so lean for Matt. We would have had to sell our car; he would have taken a second (or third) job; I may have taken a job. We would have made it work, though thinking through those prospects of how that would affect our family, our kids who would rarely see their dad, it makes us all the more repentant of the poor financial choices we have made in the past and convicted of how we have placed our family in a very precarious and unprotected spot in the face of financial emergencies.

So mid-August we pushed into the Third and final Appeal process, where our case would be reviewed by and External Independent Review. We prepared our final documentation and rebuttal to the Big Insurance Companies denial statements. By now the packet submitted to the Review Committee was exactly 308 pages long. I kid you not. This was the last review, we would be left with very few options after this. Sure, we could sue and take them to court, but our wise Lawyer advised even if we won, we would likely incur as much in legal fees as our original bill was. It was a turmoil of emotions. I had lost faith in the System. It was so obviously corrupt, unjust in light of how obvious my circumstances were. We received the decision letter back today.

I had prepared myself for the worst. The second sentence reads: “The IRO (Independent Review Organization) has determined the Panel’s (Internal Big Insurance Company) denial should be overturned. A copy of that report is inclosed.”

I have been jumping up and down. Now I can talk about this, and talk about it in utter awe and gladness of the results. For those of you who have walked with us in what we’ve been going through, I hope this news is a relief to you as it is to us. I hope that this story, the struggle, might aid someone else in a similar predicament. At least I hope it makes you think in regards to opinions and preconceptions of Insurance regulations. I’m glad that in reading this you can celebrate along with the hours of work and heartache that went into this fight. In the IRO response, the language echos what I have typed over and over again (and sorry if this is TMI):

“Based on the records sent for evaluation and the plan language, the prior denials should be overturned and the delivery and postpartum care should be covered in this case. Although the patient had clearly conceived at the end of November 2007 … based on her ultrasound of 2/22/08 there is no evidence to support the fact that she or any other “prudent layperson” would have sought advice or treatment prior to 2/4/08 when she had her first positive pregnancy test. Ms. G carefully documents that due to her lactation her menstruation was highly irregular in occurrence (in fact she only had the one menses since her previous delivery 4/1/07), that she was using contraception, had symptoms consistent with the intestinal flu that her family experienced at the end of January, and had a “number of negative home pregnancy tests” until the positive one on 2/4/08. Therefore, there is no evidence to support the fact that Ms. G was aware or could have been aware of her pregnancy state prior to 2/4/08 (or within the 6 month look back period) … Her claims are otherwise consistent  with the symptomatic confusion that would have led to the delayed diagnosis of pregnancy in this case. … The decision reached by the expert reviewing physician is to overturn the previous denials of this claim.”

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