How I fought my HMO and won – without a lawyer

How I fought my HMO and won – without a lawyer

In January of 1990, I was in a serious snow-skiing accident. Traveling about 50 miles per hour, I fell and one of my skis sprang up and struck my head just one half-inch under my eye. My front two teeth were completely avulsed, I sustained bone damage and, resultant from a plastic orthodontic retainer I was wearing that broke apart on impact, I lacerated my tongue, lips and gums.

My sister, searching the crash site immediately after I fell, found my two front teeth in the snow — completely intact.

I was rushed to a hospital where a doctor cleaned and prepared my wounds. The following day I saw an oral surgeon who re-implanted my original teeth into their sockets. Soon after, an endodontist performed root canals on the two re-implanted teeth.

All the medical costs incurred were covered, at first, by my dental plan (until that ran out) and later my medical plan came back in, reimbursed the dental plan and paid the balance.

In 1994 I moved from Washington (state) to California, all the while maintaining continuous health insurance coverage and getting routine dental and health exams.

First Sign of a Problem

On October 6th and 7th, 1995, I participated in a 200 mile running relay race from Calistoga to Santa Cruz, California. Each of the 8 members of my team ran three legs of the race (approximately 8 miles each.) In my second leg of the race, I was running up a hill between San Francisco’s Ocean Beach and Pacifica. As I reached the top of the hill, a mild headache I had became a serious problem and the front of my face began to pound. I attributed the problem to fatigue. I finished my second leg and, a few hours later, ran my third.

The day after the race, still in much pain (which I still attributed to fatigue), I woke in the night to a “popping” noise in my mouth. I rushed to a mirror and felt around where I heard the popping noise. A small discoloration was visible in my gums just above my upper-left front tooth. The left front tooth was extremely loose – as if the tooth was not anchored to anything.

Over the next few days I called several doctors and my insurance company, trying to figure out what to do. I opened up my medical plan’s evidence of coverage and studied it. I made arrangement to visit an oral surgeon in Palo Alto. All the while, I was experiencing extreme discomfort: the slightest movement resulted in a burning pain in my gums and, occasionally, a sharp pain shooting from the my left tooth to just under my left eye. I was unable to eat most foods, I had a very difficult time talking and I seldom slept. At the time, I did not own a car (by choice) and my mountain bike and the CalTrain were my only modes of transportation. My condition made running errands very difficult (this was mostly the result of the pounding headaches I experienced when my heart rate went up.)

Seeking Treatment and Coverage

On October 19th, I could take the pain no longer and called my surgeon (whom I was to meet with on the 26th). He referred me to a dentist and I immediately made an appointment. The dentist x-rayed my teeth found severe root and bone loss in and around my upper two front teeth.

On October 26th, I met with my surgeon who took more x-rays and explained my condition and alternative treatments.

On October 31st, I met with my primary care physician (PCP) who examined my x-rays, discussed the matter with me and then made a referral for my treatment with my surgeon (who was an out of plan provider.) I did not have dental insurance, only health insurance. My PCP’s referral was immediately denied as “dental care not covered”. My surgeon and PCP both appealed the decision stressing the importance of the immediate treatment of my condition. The denial was upheld and I began the “grievance and appeals process.”

After carefully studying my options and discussing the matter with my doctors, I decided that implants would be best and most conservative treatment.

Over the next 14 months, I had at least 50 total appointments with either my surgeon, dentist and PCP. I had five surgeries: one to remove my infected teeth, the adjacent bone and to perform a bone graft; another to remove a surgical membrane and examine the earlier graft; one to place two titanium implants, a bone graft and a third titanium screw (for structural purposes of the graft); a fourth to remove a second surgical membrane and graft tissue from by palette to my gums; and a fifth to place abutments over my implants (which will later support porcelain teeth) and perform some other work on the tissue graft. My medical bills total approximately $13,000.

Battle for Coverage

After examining my health plan, I found an allowance for “oral surgery services” which were the result of “accidental injury or congenital defect.” There was no specific time window given in which the injury was to have occurred, nor was there even a casual reference to such a time period (such as excluding injuries which occurred outside of plan.) There was, however, an exclusion in the plan which simply said, “all dental services are excluded.” I had a dilemma: considered one way, my condition was covered, yet another way and my condition was not. I felt the conditions for either case were not sufficiently defined and, interpreting the plan in my favor, felt that I should be covered.

I based my appeals on three claims: i) my care was medically necessary; ii) my condition was accident related; and iii) my condition fell within the allowed area and was not excluded by the “dental services” exclusion. I would argue that my “accidental injury” was the January 1990 ski wreck.

My plan continually denied for a variety of reasons. Every time I was able to overcome their arguments, they found another reason to reject my claims. Some of the most common rejections were for: i) seeking treatment outside of plan; ii) my condition being “purely dental”; iii) my accident having occurred too long ago to be considered as the cause of my present condition; iv) refusing to visit a referral doctor when a referral was made; and v) for failure to comply with referral guidelines set forth in the plan.

I was able to overcome many of their arguments: i) I sought treatment outside of plan only because there were no specialists within the medical plan that were listed in their provider list and, further, they refused to make a referral to an plan provider in a reasonable time consistent with the severity of my condition; ii) my condition was not purely dental, but fell within the “oral surgery” clause due to its severity and especially the extensive bone work required by a specialist (an oral surgeon); iii) the plan’s evidence of coverage did not specify any time frame to which they referred in their denials; iv) when I did receive A referral for a dental plan dentist (even though I was in the medical plan and a dentist alone would not be qualified to treat me), their own dentist, after my first surgery, took an x-ray and said that there was no way for him to tell for sure what the original cause of my problem was because I had major and extensive work that work that was consistent with the condition claimed — their doctor suggested the plan contact my surgeon and re-examine my x-rays (they never did.)

I sent at six formal appeal letters and at least three faxes to my insurance company as my appeal was passed between at least a half-dozen different employees (often while at the same level of appeal). The insurance company lost documentation, misstated facts, did not follow up with request for information and refused to discuss the matter with my surgeon, dentist, PCP and their own dentist (that they referred me to.)

In nearly every letter I wrote to the insurance company, I listed my surgeon’s and dentist’s address and phone number and requested they contact my doctors to personally discuss the situation—that my condition was far from routine and needed a specialist’s explanation. I tried in simple lay terms to describe the pain, discomfort and bone loss I was experiencing and what the result would be if the condition were allowed to continue untreated.

My doctors also wrote letters. My PCP appealed the decision and was reprimanded. My surgeon wrote numerous letters but was completely ignored.

In all, I have in my possession well over 100 pages of correspondence between the various parties involved. Three tiers of administrators managed my plan. Communication between the tiers was terrible: months passed in which no response or notice of any kind was sent to me. In one instance, I faxed a letter to my insurance provider January 20th, which my provider passed on to another department February 28th, which that next department made a response to March 14th and which was finally mailed to me on April 23rd. Over a 3 month response time!

I kept detailed notes of phone conversations with fields for: the date, the time, the name of representative, questions I asked, and the answers they gave me. In my notes, I have the names of over twenty people in various entities associated with my health plan that I talked to at some point in time. By October of 1996 (the one year anniversary of the beginning of my battle), I had over 67 phone calls logged into a spreadsheet.

Showdown

In the beginning of October, a request for a hearing that I made in June was answered and a hearing date set for late October. I carefully prepared for the meeting: I collected all my documentation and notes; reviewed and organized the notes in two ways (by date and by originator then date — so I had two copies); I summarized each document in one or two sentences and then prepared my arguments (in written form.) I narrowed my arguments into five questions I would ask at the hearing. I then sent all my documentation and notes (with a copy of the plan’s explanation of benefits) to the hearing officer. I declined to bring a witness with me because my insurance provider told me (in a letter) that they would not be bringing lawyers, doctors, or other medical professionals because my hearing was “informal.”

When I showed up for the hearing, a doctor and a nurse were present who were not listed on the witness list my HMO sent me. I immediately asked why they were present because I was specifically told that the meeting was informal and that I had volunteered to bring a doctor (as a witness) with me if I would be assured that I would not be bringing a doctor to talk to lay people (which I felt was a large part of my problem) and vice-versa. The hearing officer didn’t volunteer an answer nor did the doctor. The doctor suggested that he could pen his and the nurse’s name in on the list I had and that would make my list complete.

The doctor ran the show. He continually attacked me on the grounds that services I was receiving were dental and not medical. When I explained my diagram (see Figure 1) he simply said that I was confused and that the care I was receiving was strictly considered a “dental service” because the individual who was treating me primarily worked in and around the teeth. I asked the doctor on what part of the body an oral surgeon normally worked (according to the plan) because if “in and around the teeth” was a criteria, then the oral surgery clause should not even be in the plan because it only obfuscated the issue. He simply said again that my condition was defined by area of practice the individual who treated me normally worked. I told him this was ridiculous and that a condition should be treated based upon its merits, not simply on who treated it.

Even though I knew it was taking his statement much too far, I gave an analogy of someone in a car wreck who dislocated their shoulder. A dentist stops to assist before paramedics arrive and sets the injured person’s shoulder. I asked: If the dentist billed the your company a reasonable amount for his services, would you deny it as a “dental problem?”

This frustrated the doctor quite a bit and the hearing officer actually intervened, acknowledging “a gray area in the plan in the distinction of dental and oral surgery services.” She did, however, say that they had books they used to determine whether an accident occurred too long ago. I asked what, precisely those time frames were and was told, “about a year before the problem shows up.”

I asked the hearing officer where I could get a copy of the books she was referring to and what, precisely the book said. She said the books were confidential only because it would be too expensive to deliver them to all the people subscribing to a plan. She added that the book didn’t give a “precise” a time frame. (Of course, I too have secret books I used to determine whether my condition merited coverage under the plan…) I suggested the Internet might be a place to publish such a document or that they could be disclosed upon request. I added that someone should have shown me the line in their secret book 12 months ago because it would have saved me and dozens of people hundreds of hours of time, lots of postage and even more paper.

I continued to press the doctor and hearing officer to find the specific language in the plan that might clear up the ambiguity between “dental” and “oral surgery” services as well the time frame in which the accident should have occurred. They could find nothing in the evidence of coverage and offered no suggestions.

After running around in circles for about two hours, all present were clearly frustrated and the hearing officer closed the meeting asking me if I had anything to add beyond the specifics of my disagreement with them. I did…

My Little Soap Box

I started out by explaining how I faithfully pay my bills every month which include a partial deduction from my paycheck for the plan. I said that I feel my insurance provider has a fiduciary responsibility to cover medical costs necessary for my well being—something given for something gained. I did not, however, feel it was my insurance provider’s responsibility to cover frivolous claims and that I expected, at the slightest sign of a questionable claim, they should investigate any uncertainty. However, even with overwhelming evidence from my doctors (x-rays, letters, etc.) and even at my continued request to contact my doctors and investigate my claims, they refused to do so.

I asked if they could tell me who examined the x-rays (from years of examinations since my wreck) that I sent them and asked what that individual’s conclusion was. No answer. I told those present that their plan was walking a very fine line: front-line people who examine the merits of case who are rarely medical professionals are making “yes” or “no” decisions on health issues which may preempt the recommendations of my doctors. My doctor says “seek this treatment” and my insurance provider says “you can’t seek this treatment.” What am I supposed to do?

I then addressed my frustration of dealing with the plan. I told them of the web of people I had to deal with who handled various portions of my appeals and how each made small clerical and factual mistakes that were so compounded by the end of the process that they completely distorted my case. Many of the insurance provider’s employees completely mislead me (innocently) and gave me improper advice, others were short and indifferent and were all too eager to pass me off to an unwitting colleague (due to the complexity of my situation.) Forms and letters were sent to incorrect addresses (even my name changed three times) and where so cryptic that even the writer couldn’t explain what the letter was supposed to mean when I called to inquire.

I told the plan’s representatives that they could sit in their glass tower and read paper all they wanted and that that paper could never tell the terrible stories and frustration of all people that suffer and do not have the stamina and persistence to take on an entity as large as their insurance company. I told them how I had doctor’s appointment nearly once a week, every week for the past year and that I was x-rayed, poked, prodded and had samples taken nearly every visit; my surgeries, of course, were worse with so much manipulation of bone and tissue that two of the surgeries caused my face to swell so large that it cracked my skin and caused bleeding.

I added that people much worse off than me are being denied every day and there is nobody to speak up or fight for them. Three times I tried to get a lawyer to fight for me, but because of the way the plans are protected under federal law (ERISA), no lawyer would take the case on a contingency fee basis before the grievance and appeals process was completed – because they can’t get punitive damages (only the total of the claims) which would normally cover the attorney’s fees. I said that people see what happens in glass towers and, as one lawyer told me, it is “settlement though attrition”: most people can’t or won’t fight because they don’t have the time or the strength to do it, even though they have legitimate claims against the insurance company. For the insurance company there is no down side. They can deny legitimate claims with impunity: if you file a state case against them (where you can get punitive damages), they will preempt it with federal law (ERISA), or, in the event you don’t try and sue, they can (and will) deny the most meritorious of cases clear up until the end of an overly convoluted process. Fortunately for them, if they do settle in the end, they will only have pay what they should have paid to start with. No interest. No fees. No lost time. Nothing.

When I finished, nobody said a word. I packed up my documents, thanked them for their time and walked out.

A Decision

15 days after the hearing I received a letter from my insurance provider stating “we are happy to reverse our denials and rule in your favor.” They have agreed to reimburse me dollar for dollar. Their letter was dated November 12th and I’ve been paid 1/3 of what is owed so far. The remaining 2/3 is apparently processed and, as of January 15th, “a check is in the mail.”

UPDATE: The January 15th date came and went. But as of April 3rd, 1997 I’ve been paid in full (less my $200 deductibles for my ’96 and ’97 bills and some disputed change.) In all, approximately 95% of my bills were paid.

I wish I could pay my premiums on such a relaxed schedule. Actually, I wish I could pay any of my bills on such as schedule!

Reflection

I spent hundreds of hours researching, thinking and composing my thoughts. My problem, due to the cavalier attitude my insurance provider took with me, quickly became a matter of principle and eventually a crusade. I held my ground and never gave an inch (which, I can tell you from experience, is not necessarily a good thing) because I truly believed in what I was fighting for.

There were days I woke up and felt like I was too weak to fight, and, right up until the end, even after I walked out of my hearing, I thought I had lost, even if it was some consolation that I had “fought a good fight.” If you fight a battle and do it from your heart, you really can’t lose. The advantage I had over my insurance provider was that I had passion and spirit and they didn’t. In the end, I think that passion and spirit are what won my battle.

They say hindsight is 20/20 — I certainly wouldn’t do everything the same way, but I quickly learned and adapted to my environment.  This is my Informal Guide to Appealing Health Insurance Claims.

Simple Rules

  • Educate yourself about your condition: ask your doctor(s) and your HMO lots of questions. Do not be shy.
  • Know your policy: read your evidence of coverage (which is your contract with your insurance provider) and carefully assess how the plan could be interpreted in your favor or in your insurance provider’s favor. Be familiar with the referral process and the grievance and appeals process.
  • Carefully document everything: take copious notes and don’t let the slightest phone call go undocumented. Keep a notebook or journal if possible of the factual events that transpire. Make folders and keep them organized.
  • Write simply: Make your letters as short as possible (but include important details) and with each response to a letter from your HMO, request to move the next stage in the appeal process.
  • Always be polite and courteous: try not to be short or mean on the phone, in person or in written letters. Don’t be so nice as to let someone walk all over you, just nice enough that they won’t dread dealing with you. (I encountered three individuals in my case that were very concerned about my condition and worked hard to try and resolve my problem — had I not been polite and courteous, I might never have been given the help I received.)
  • Never give up: don’t let the insurance company intimidate you with letters you can’t understand or demands that are unreasonable. If the insurance company is attacking you on procedural grounds alone, you might have a good medical case that they are avoiding addressing.

Ways To Improve the System

  1. Mandate strict penalties for insurance companies for not responding to letters or inquiries in a timely manner. In my case, as many as 3 months went by where the insurance company did not respond to my letters. This should not be tolerated, but by the same token, an individual should not be allowed to flood an insurance company with unreasonable requests for information.
  2. Make insurance companies pay a premium interest rate on claims when settling with an individual. Prime + 8% sounds nice to me. Give the insurance company some incentive for speeding up the grievance and appeals process. In my case, I paid all my doctors as I went because I honestly did not know what was going to happen.
  3. Update the Employee Retirement Income Security Act (ERISA) of 1974. This act is usually what prevents individuals from being treated fairly by their insurance provider. The act was passed into law long before managed care existed and does not anticipate individuals having problems resolving insurance claims disputes. Unfortunately, there does not seem to be much momentum at the grass roots level to overcome the insurance lobby, so I?m not optimistic about this changing any time soon.
  4. Make insurance providers fix the grievance and appeals process so it is simple and intuitive. Plans should clearly spell out the process and put limits on how long or how many appeals are made in each level before you are automatically moved to the next level. In my case, I was pushed all over the place – from one level to another and then back again. On one occasion, I made it to the next “level” in the process and someone found a clerical mistake by an individual at the insurance company, so they sent me back to where I came from.

My way is not the only way and I encourage others who have been through a similar ordeal to share their stories or to give advice that I am missing.

1 Comment

  1. I had (2) dental implants done with bone grafting, beginning in October 2013.
    It takes time because you have to wait (3) months to heal in between procedures.
    Come to find out, that in January 2013, the IRS discontinued, our right to submit $13,000.00 (same as you!) for “artificial teeth”. It is no longer deductible on our taxes! Can you believe it?
    They allowed it up until the year I was able to get it done.

    Mine have both failed, one was removed, redone and failed again. I have no more money to pay out, and the only way to get it removed, is for me to pay. My periodontal surgeon is just not dealing with me anymore.
    They pretty much force you to report them to PUBLIC HEALTH and/or hire an attorney.
    I think he should at least, foot the bill for someone else to remove and do something to make me “whole” again.
    I did not sign up to be financially worse off and ugly.
    Why do these surgeons think we should pay, to fix a “failure”?
    Is it not cheaper for them to just deal with you upfront, instead of heading to court?
    I hate lawyer and the justice system is a joke anyway.
    Good luck to you. I was denied for the exact same reasons, and I have DENTAL INSURANCE!

    Reply

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