Post-script to bureaucracy, now-found documents and health insurance. . .

June 11, 2007 | By | 4 Replies More

For those of you who waded through my post of last week about my day trekking through the federal bureaucracy on a quest for documents, I have two things to add. First, thanks for taking the time to wade. Second, I got an update from my friend. Remember those records that everyone told him were in “the Archives” in Kansas City? Two different archives, even, if I understood correctly, one in KC and one in Lee’s Summit.

Well, he found those very records, and didn’t have to travel further than the local library. OK, the main library, the headquarters for St. Louis County Public Libraries, in the genealogy room. He found the microfiche with all of it, and got through several years without finding the naturalization papers, which he knew he wouldn’t. So now he can call the helpful woman whose name he was given and tell her that he searched and didn’t find.
No one mentioned the library. Not one employee with whom he spoke, state or federal, knew about this. Hmmm. Secret files? Good thing they hid them so carefully.

On a semi-related note, another friend is wading not through governmental bureaucracy, but insurance bureaucracy. My guess is that every single person who reads this knows someone who has had to fight over health insurance. My friend’s son was scheduled for major surgery this week, the (hopefully) final step in the correction of a cleft palate and lip. As most of you know, clefts of this sort are birth defects. Rarely does a palate or lip spontaneously split . This boy is now a teenager, and has been through all of his corrective surgeries at a large, well-known and well-funded teaching hospital here in St. Louis. Their insurance is through the same university, as his father works there. Every surgery he’s had has led up to this one, the alignment of his jaws. They started when he was a baby, and this one had to wait til his skull reached full size. He’s 17 now, and the entire family scheduled the summer around this surgery, months in advance. He held off getting a job, because the recuperation for this one is tough. Annual trips typically taken in June were delayed, and they prepared to finally get this done so that he can finish high school and put this all behind him.

Days, literally, before the surgery, she received a phone call from the coordinator of the cleft palate team, telling her that the insurance had declined the surgery. They don’t cover orthognathic surgery, or the realigning of jawbones. My friend was utterly stunned – this has been in the offing for years, same insurance they’ve had since they brought their son home. After some tears, followed by the wringing of hands and gnashing of teeth, she took a deep breath and headed to the insurance carrier’s website, where she waded through all the pages she could find, but not anything about this exclusion. She took another, deeper breath and contacted the company by phone. Through extremely nice manners and by withholding all of the rage she was feeling, she managed to find someone to pull up her file and find the applicable section: They don’t cover orthognathic surgery, EXCEPT IN THE CASE OF BIRTH DEFECTS. Oh, really? So how exactly did that little tidbit slip by? Don’t insurance companies actually examine the cases they review? This child’s entire medical history revolves around his cleft and its effect on his sinuses, his face, his skull and his jaw. How did they miss that? I guess they find it easy to just stamp DENIED across the page when they see the single word, “orthognatic,” without examining it any further. Do they not know that clefts are a common cause of this? Are the case reviewers not trained in any level of actual medical terminology? Or was this an honest mistake, an accident caused by the random human error?
I really felt for my friend – she loves this child so much, she’s advocated for him for years, and now to have this last layer of intervention denied . . . I was simply furious on her behalf. The hospital has filed an appeal, and the insurance company has 72 hours to respond.

Hopefully, in a few short days the surgery can be rescheduled in a timely fashion – but no one involved is holding their breath, because this isn’t about what is best for this child – with insurance, it rarely is. This is all about how to save the insurance company $80,000.

And the thing is, I’m sure this is nothing compared to what many have gone through. At least they weren’t denied after the fact, after they’d unwittingly dived deeply into debt. At least they didn’t open him up and then learn, at the 11th hour as he lay in surgery, that they better not proceed. At least his life is not in danger. No, he’s just a kid, a straight-A student, a normal suburban kid, a child dreading a surgery he knows is coming. And they are just normal parents, trying to help him, by paying their premiums on time and doing their best by their child.
I’ll post again when she calls with an update.

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Category: American Culture, Health, Medicine

About the Author ()

I am a writer and communication professional in St. Louis, Missouri, a crafter of jewelry, a disorganized optimist and most importantly, the adoptive mom of two China-born daughters.

Comments (4)

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  1. Erich Vieth says:

    I'm tired of being patient with insurance companies. Let's reinvoke the "eye for an eye" rule. If a medical insurance company employee wrongfully denies you coverage for fixing a broken leg, let's break that employee's leg. That will get them paying better attention to the full language of the relevant insurance provisions.

    I'll confess that I worked as an attorney for insurance companies for many years. That company wrote the provision in question. Any potential ambiguity as to how to interpret it should be construed against the insurance company. But there is no ambiguity here, based on what you write. This is clearly a birth defect and the exclusion doesn't apply to birth defects. Sounds like the insurance company denial is meritless. Do update us with the result.

  2. grumpypilgrim says:

    I once had my own run-in with an evil health insurance company. The saga is too long to explain (the letter I sent to the company describing their long series of screw-ups was nearly four pages long), but the gist is that they had a policy that had already cheated a number of other people and it was still in place when they tried to cheat me with it. The solution is to document everything, to write letters to key officers of the company, and to "cc" everything to the state insurance commissioner and the state office of consumer protection. In extreme cases — such as when the insurance company has already cheated other people and is still doing it — a threat to contact the media can also get attention.

  3. Mary says:

    I had a temp job doing filing in an insurance agency once. Mercifully, it only lasted a few weeks. While there, I heard one of the workers advise another insurance person on the phone NOT to tell a pregnant woman what was covered and not covered in her policy so they could deny her at will. I wouldn't put any policy denial down to an accidental oversight after hearing that.

  4. Tim Hogan says:

    Since the plan which your friend has is employer provided, there is a likely application of the ERISA law. Under ERISA, denied benefits may be sued for in federal court by the insured but, all you get is the not provided for benefit and maybe your attorney's fees (not required).

    I've filed such suits on behalf of families which have had members with MS, which is a neurological disorder, where the insurer argued there was an exhaustion of a lifeltime limit of psychiatric care and denied benefits.

    We argued successfully to the insurer that the condition was a medical condition but, were only paid in settlement the amount of the uncovered expense.

    I had to negotiate with the provider to decrease their lien so as to pay my attorney's fees because I didn't see the fairness of making my client pay me to get something which they were already entitled to by contract.

    In your friend's situation, if they can work something out with the employer/provider in advance to accept the payment from the proceeds of a suit and have the insurer tell them also the names, addresses, policy numbers, policy language and phone numbers of all similarly situated persons which they declined coverage for orthagnic surgeries where they were caused by birth defects, someone might be able sue the insurer on behalf of all the persons denied such coverage and sock it to the greedy scum. I only got the money for my client when I sent the insurer a request for that exact infomation for any other persons which the plan had denied coverage of medical bills where the person suffered from MS and the company claimed the lifetime limit was exceeded.

    I don't do that work any more because it's only in federal court, so time consuming and you can't always get providers to waive part of their liens to get paid. I ate several of those and couldn't afford any more. The insurer offers the amount of the benefit, no fees and you have to take the offer to your client and the client has to take it but, you might not get paid which creates a potential conflict of interest. The situation may only be realistically fixed by requiring insurers to pay fees when they improperly and wrongly deny coverage or a class action, if allowed under federal law(I don't know).

    Certainly, this is not any legal advice to your friend or any other but, if you get the right folks fighting for you it sometimes helps.

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