4 year battle: Patient wins insurance coverage for a stem cell transplant--NY Times helps

[Sushi]

Dogged Persistence Pays Off, With Interest

In this episode, the story of an epic, four-year battle between a man and a health insurer. Typically, these stories end with the same score: Health Insurer 1, Patient 0.

This story is different.

It started in 2006, when at the age of 37, Dave Bexfield of Albuquerque learned that he had multiple sclerosis, or M.S. Three years later, the disease ramped up and he was forced to quit his job as managing editor of a car magazine, in part because he could not type. He qualified for a clinical trial, sponsored by the National Institutes of Health and conducted by the University of Texas MD Anderson Cancer Center in Houston. He spent three months there getting a stem cell transplant. His total bill was just under $200,000. (Yes, though sponsored by the N.I.H., the treatment came with a price tag.)...

His health insurer, Presbyterian Health Plan, declined to cover the treatment because at the time, officials said, it was not a covered benefit under the terms of the plan Mr. Bexfield is enrolled in, namely the Federal Employees Health Benefits program. (Mr. Bexfield’s wife works for the Department of the Interior, and he received coverage through her.)...

On June 24, his claim was turned down yet again.
A few weeks later, on July 7, he emailed the Haggler, describing his Freedom of Information findings. (see full article) He used the word “lie” a lot. The Haggler forwarded that email to Presbyterian’s spokeswoman.

The next day, everything changed.

The president of Presbyterian, Lisa Farrell Lujan, called Mr. Bexfield and offered what amounted to an unconditional surrender. She agreed to cover not just the original expense of the treatment but four years of accumulated interest that the money might have earned Mr. Bexfield and his family, at 18 percent. (The insurer agreed to pay that much in interest because that’s the rate it uses when it is late paying a medical provider, like a physician.)

Presbyterian has since wired Mr. Bexfield $402,000 — that’s $198,000 for the treatment and $204,000 in interest. (It adds up.)

Read full article in the NY Times here.

This video was linked in the full article.

 

[PNR2008]

Wow congrats to Mr. Bexfield!

I have a different problem with my insurance co. I got SSD in 1990 and I had a private disability insurance if that SSD didn't kick in. Well since I got the SSD the private insurance co gave me $400.00 since their payments were higher, each month. These stopped at age 65 as it says on my contract however the company doesn't have a contract since it was more than 25 years ago.

Sounds fishy to me so when I get some strength, I'll go and find the contract if I every got one from my employer. If It was given to me, then I have it in the attic. How could an insurance co lose a contract especially since they were paying on it for about 26 years?