Insurance denied request for replacement of broken unit: sorry for the rantings of an old lady

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Posted by flygal (483 posts)
May 14, 2013 11:23 PM

I now remember why I hate insurance companies, especially worker's comp.
In February I noted new pain in my right leg; saw my main w/c doctor (had not seen in about 5 years due to success of SCS) who did CT of spine to rule out new cord problems; showed no change. Went to see pain doctor (that I had not seen in 2 years due to SCS doing what it is supposed to do); he said could be broken electrode or electrode coming out of IPG. After waiting over 2 weeks for approval for plain x-ray to show SCS electrode and IPG, and no word, I went to a local clinic and got my film that showed at least one break in electrode. Went to surgeon who would replace. I was scheduled for surgery a week ago, but due to transcription delays, w/c did not get request until last Wed, 2days before surgery. No decision. Yesterday came the decision that surgery was denied. Per the w/c adjuster (the good guy; not the precert person) the letter stated that because I had not been tried on pain medications and other attempts at pain management (even though somewhere in the letter it said my SCS lead was broken), and there was no notation of any pain and disability in the request, the SCS was not an appropriate pain management tool at this time. What a joke. Currently I, who ran a 5K in January, then the next day rode my bike 30 miles as a bike medic for the marathon, can barely manage on crutches; my leg cannot be dependent for more than a few minutes before excruciating pain occurs. My only solace is flying: because I am sitting, I don't have any pain, and my legs work OK when sitting.
So now I have to wait through the appeals process, which can take a month or more. Plus my boss had told me that if I cannot work the memorial day weekend if I have surgery, then I cannot have the surgery til after the weekend due to lack of coverage. WHAT?? All the extra work I do for her and she tells me when I can and can't have this urgent surgery??
Sometimes I am so tired of this garbage I want to quit.

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Posted by jinglepaws (220 posts)
May 14, 2013 1:19 AM

Insurance has nothing to do with actually providing needed medical services but everything to do with collecting premiums while denying claims whether justified or not. It seems their latest strategy is to deny rightful claims, no matter how outrageous and weak the grounds, repeatedly hoping patients will just give up sooner or later. I guess it must work most of the time because I am seeing this tactic used more and more. I hope you have an experienced and determined billing person in your doctor's office who will keep resubmitting until they relent because that's what it takes. What they're doing is blatantly illegal but corporations rule these days and the Government just looks the other way, with a wink to the insurance industry while screwing the little guy. Persistence is the only way I finally got my implant paid for. My insurance pulled every stupid ploy in the book trying to get out of paying the bill.

As for your boss, wow!!! Management has gotten out of control due to having folks over a barrel due to the nonexistent job market. Sooner or later though, the tables will turn and then management will be forced to reap what they have sown. The saddest part is, they will be clueless as to why no one wants to work for them anymore and are leaving in droves. Are you in a position to quit? Probably not but this woman sounds like a A-1 jerk. Hope you get the opportunity to tell her where she can stick it and walk.

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Posted by VEM (205 posts)
May 14, 2013 3:29 AM

flygal, I have logged onto this forum every day to see if you had undergone the surgery needed to replace your broken lead. That is just so RIDICULOUS and to even 'suggest' that you go back on pain meds! Prayers, support, encouragement for you sweet lady. Luv 'bamaVickie

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Posted by jlboman (33 posts)
May 14, 2013 3:30 AM

You arent ranting. You are frustrated. Can your private ins pick this one up instead of WC?

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Posted by flygal (483 posts)
May 14, 2013 4:33 AM


Thanks; I so much agree. Reminds me of the movie The Rainmaker: insurance plan: deny without looking at case; then deny again, then deny again, waiting for insured to die so they won't have to pay. Unfortunately for them I am somewhat of a fighter, as is my BSC rep and my surgeon office.
I totally agree about my boss as well. I make her look really good with her bosses, doing alot of extra things that many in my office don't know I know because of my past experiences. Sometimes all they see is a gimp. My boss knows better, and even said when the surgery first came up that she had asked another employee to delay surgery (minor hand surgery, totally elective) due to scheduling. She said mine was different because it was an emergency. Then for her to pull that "you can't have surgery now unless you can work for me Memorial Weekend"? I wonder what would have happened if I had the surgery last week, and had not recovered as fast as I did after my first surgery? And what will happen if my surgeon gets approval for the surgery the week before Memorial weekend? will she fire me?? I doubt it, but she can make one's life miserable.
I wish I could ask for my primary to pay for it, but am 99% sure that would not happen. Not like this is a new unit installation; it is to replace one. As soon as they learn it is covered by another insurance, I would have to pay the total bill, plus I am sure insurance, and would be charged with insurance fraud.
I appreciate any and all prayers that I am able to make it through this period holding my head high. When my healing time is over I plan on restarting my training for a sprint triathlon! which was my post-January race goal. You and I both know I can do it! It just might take a little more training.
Thanks to every one here: you are wonderful and caring.
flygal

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Posted by jinglepaws (220 posts)
May 14, 2013 5:42 AM

I sure wouldn't break my backside doing those extra, unrecognized (and, apparently, unappreciated) tasks after this. Your boss certainly is not breaking her backside to help you in any way. She has shown what kind of person she really is and the fact she doesn't give a damn about anyone but herself. Do your job and do it well, just don't give anymore than you have to. She's a user and a loser!

I'd hound W/C to the max. If you just can't get it out of W/C, I'd hit up my primary carrier. Something tells me BS will use their know how to get it paid for by insurance since it means big money in their pocket. Question is, how are you going to survive with the pain in the interim? I'll keep you in my prayers.

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Posted by flygal (483 posts)
May 14, 2013 6:18 AM

JP
I am lucky to have a proactive rep; he went to the surgeon office today and read the denial letter (and agreed it was foolish without grounds for denial); I sent him a letter with the before-break me and the after-break me (from runner to crutcher); and will be following up. I have actually tried many times both yesterday and today to get ahold of the precert department, but only get voice mail, or "all reps are busy helping other customers" and then "please leave a vm on this private line". Yea, right! I did that yesterday and no call back.
I am a survivor (There is a song out by Matthew West with that name which is so true!) as are all of us. I have minimized what I do to minimize the pain; I cannot take any narcotics etc so I can keep flying (my only solace right now besides my husband that takes wonderful care of me). I have my faith which keeps me strong, and I listen to my music, which helps me deal with the pain.
I know I will make it to the decision to approve the surgery; it took 6 months for them to approve my initial implant; I just hope it doesn't take that long for the new one.
We are all survivors; otherwise we would have given up and laid down and died. We refuse to do that, because we will do almost anything to get our lives back, right? "Normal" people don't know what inner strength is; we rely on it every minute.
flygal

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Posted by KittyPal (38 posts)
May 14, 2013 8:57 AM

I was logging on this evening to do a little "whining"; my pain is up, I am frustrated and tired and have an "all or nothing" boss who continues to push things. It is hard to keep going sometimes. As I read your update, Flygal, I began thinking about the level of pain you must have right now and the politics you are dealing with in order to get that lead fixed. What strength you have! Thanks for sharing the Matthew West song...it is wonderful! We are a group of survivors. I then found his song, "The Healing has Begun" and by the time I got to the end of it my pain began to settle. No boss, insurance company, rep, programmer, surgeon and more can stop your love of running and flying and preparations for a triathalon. The last song I just listened to made me think of the freedom you describe while you are in the cockpit, "Take a look at the mountain Stretching a mile high Take a look at the ocean Far as your eye can see And think of me" (Matthew West). Have a good night. :) I'm excited to learn how much stronger you feel and find a decrease in your pain when that unit is working properly.

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Posted by flygal (483 posts)
May 14, 2013 10:11 AM

Kitty,
Thank you so much for your other Matthew West songs; I added them to the music I listen to when I really hurt; I really like the mountain song, since I used to live in the mountains and miss them alot.
I love this group so much because I can come here hurting both physically and emotionally, and am so lifted up. Thanks everyone for being here both in good times and bad.
flygal

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Posted by VEM (205 posts)
May 14, 2013 10:37 AM

I agree w/JP & KP....prayers from 'bama for U. We all KNOW that U R indeed a 'fighter'...we are here w/U every step of the way, crutches and all, whatever it takes. Love support prayers and caring hugs for U sweet lady. Vickie

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