A woman dressed in a karate uniform stands with her palms together with an angry expression looking at an insurance form with a big red stamp on it meaning it was denied.

Advanced Health Insurance Fighting

Last summer, I had a swift and serious infection that landed me in the hospital. Thankfully it was a short stay and I received the care I needed for a good recovery. Although I wasn’t happy about what happened, I knew my doctor was right in sending me to the emergency room to get admitted.

Unfortunately, after I came home and recovered, I received a letter from the health insurance company that they did not agree and declined to pay my hospital bill. This letter inspired wrath for which I did not know I was capable. (Live and learn!) But it spurred me and my husband (Richard) into action.

My hospitalization was deemed “medically unnecessary”

Richard called to find out more, but the information was very limited. They wouldn’t tell us what they based the decision on except that they found hospitalization to be “medically unnecessary” and that I could have received outpatient treatment. Somehow, they ignored the outpatient visits where I didn’t get effective treatment before my doctor sent me to the hospital.

Starting the insurance appeal process

The first step was to submit a standard appeal to the health insurance decision. In this the records are re-sent and we didn’t do any additional work. Yet, in opposition to all the facts, the health insurance denied the claim yet again within a short time (strongly suggesting no additional review was actually completed).

Explaining my medical history and treatment experience

The next step was to collect the records myself and work with my doctors to write and submit letters. The short version of my letter and also what the doctors submitted was that I have a 40+ year history of aggressive rheumatoid arthritis resulting in significant disabilities, such as using a wheelchair. My history and treatment with immunosuppressant medications mean that infections are serious and may be life-threatening when not effectively treated.

I had visited the outpatient clinic but was unable to get treatment that worked on the skin infection, which was quickly worsening (threatening sepsis or blood infection). My rheumatologist correctly directed me to the ER to get admitted to the hospital so that a team of doctors (general, rheumatology, dermatology, and infectious disease) could consult and work together to fight the infection. This was the most logical and cost-effective approach available for my condition at the time. And it worked! They were able to get me on a working treatment and I was only in the hospital for two days.

Take your time to tell a coherent story in the appeal

It took a couple months to get all the letters completed and pull together the packet. One aspect that made me particularly angry was the implication that I incorrectly went to the hospital. It is a point of pride that I don’t go to the hospital (probably even when I should) because I want to solve things myself and not be ‘locked up.’ In fact, the last time I was in the hospital was for my knee revision surgery seven years ago. Before that, I was last admitted when I was in college 20 years ago for a broken leg.

All of this was noted in my letter, along with a paragraph stating that if they failed to correct this decision, I would appeal to my state’s health ombudsman office where I felt confident the facts would prevail. I honestly believe they needed to know I would be appealing infinitely (or as many times as possible)—that I would not give up the fight.

The health insurance denial was overturned

After another month (or five months after my hospitalization), we finally received notice that the health insurance denial was overturned and my hospital bills will be paid. I fully believe that it was not the facts that overturned the case, but instead the demonstration of my unwillingness to accept the ridiculousness of this denial and intention to appeal them to death that won me the case.

Sometimes, demonstrating stubbornness wins out

My rheumatologist said to me: “You know Kelly, it’s all about the money.” And he is right. The health insurance wants to take my money, but they don’t want to pay out for my care. Increasingly in clear cut cases, they are fighting patients who are too exhausted to fight this fight—which means they win. They are burdening both patients and doctors (who now have to repeatedly justify their medical decisions) with these fights.

But as long as I have the patience, energy, and time, I will be kung fu fighting health insurance companies to ensure that I am receiving the care that I deserve and for which they have promised to provide coverage.

 

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