Maryland Injury and Disability Law : Washington DC Metro Injury & Disability Lawyer & Attorney : Greenberg & Bederman : Accidents, Falls, Medical Malpractice : Maryland, DC, Virginia

JD: Exactly. There was nobody at fault here. It was just a straightforward accident.

GB: What happened next?

JD: Well, I managed to get my cell phone out and called 911, and the ambulance came right away. It certainly felt like a long time before they got there, considering that my leg was broken and I was lying in the snow. But actually they got there within minutes. They got me squared away and put me on the stretcher and put me in the ambulance and away we went.

GB: So far so good.

JD: I have to say, honestly, that the medical treatment I got was outstanding. Everyone, from the EMT’s to the doctors to the nurses, they all handled my care about as well as it could have been handled. I was put in a cast and was in the hospital for a few days because it was a very severe break. I had a plaster cast on for about eight weeks, and then I moved on to a soft cast.

GB: When did things start to go bad with the insurance?

JD: Almost immediately. Have you ever seen that Michael Moore movie, Sicko?  You know that scene where the woman who got hit by a car had her ambulance ride denied because it wasn’t preapproved? That was exactly what happened to me.

GB: They refused to pay for the ambulance ride because you didn’t call ahead for it? How were you supposed to do that?

JD: Those are some pretty rigid expectations, aren’t they? As a science reporter, I have a solid understanding of gravity, and I can tell you that it took me approximately one quarter of a second for me to hit the ground after I slipped on that ice. Even if I had the best cellular coverage in the world and the fastest fingers of any man alive, one quarter of a second is not nearly enough time to call your insurer to make arrangements for an ambulance ride.

GB: Did you appeal that denial?

JD: Well, fortunately my employer has someone on staff that handles things like that all the time. According to her, the ambulance ride is something that is almost always denied by the insurers. To them it’s just a way of negotiating lower costs. They go over the claims with a fine tooth comb, and they look for anything that they can possibly get away with denying. So she appealed it very quickly, and United Health Care realized that the standard denials weren’t going to work here, so they eventually ended up paying for it. But that initial denial gave me an idea as to how things were going to go.

GB: So how did this end up turning into $30,000?

JD: Well, when I went in for a follow up some weeks later the doctors looked me over and recommended me for surgery. The break was very bad, and they decided that to keep me from walking with a bad limp for the rest of my life, they were going to have to operate and insert two steel rods. The doctors went ahead and informed the insurance company, and booked me for the surgery. The night before the procedure, United Health Care informed us that they decided that they weren’t going to pay for it.

GB: On what grounds?

JD: They were convinced that the surgery was voluntary and not medically necessary.

GB: Not walking with a limp for the rest of your life falls under the category of “not medically necessary?”

JD: I don’t think they really believe that. I think it’s more along the lines of anything that has a five figure price tag can fall under the category of “not medically necessary,” whether it is or not.

GB: Was the surgery delayed?

JD: Actually, it wasn’t. The surgeons got on the phone and argued quite fervently, which I am grateful for. It is my understanding that there are some medical professionals who are so worn out with wrestling insurance companies that they don’t even bother anymore. But these surgeons got what they thought was approval and went ahead with it.

GB: What do you mean by “what they thought was approval?”

JD: Well, it turned out to be a tentative approval. Once the surgery was completed United Health Care went over the claim with a fine tooth comb and decided that having two surgeons handling the procedure was one too many. They argued that the procedure could have been done by just one surgeon, so they were refusing to pay for the services of the second one. That was the major cost, as well as some other denials that our company representative referred to as “standard denials.”

GB: “Standard Denials?”

JD: Denials like the ambulance ride, which are apparently denied as a matter of routine. So what with the standard denials and the surgeon that they weren’t paying for, I started getting bills in the mail for $30,000.

GB: So what happened after that?

JD: That was when it started to get really ridiculous. For one thing, my employers acquired the services of an attorney, not to handle everything, but just to help advise them through the process. The first thing the attorney told me was to not pay them a dime, mainly because if I did that would be considered a willingness to accept their decision. So basically every week I would receive five or six bills for staggering amounts of money.

GB: What was the reaction of the insurance company?

JD: Well, one thing that they kept doing was switching adjusters on us. So every time that we tried to call or e-mail, we would get a new person who knew nothing about the case, so we would essentially have to start from scratch, because they would use the first reason for denial that was initially offered, and then they would have to “deliberate” again, and then they would use excuse number two, and then they would have to “deliberate,” and then excuse number three, and so on and so on, and then they would switch adjusters on us again, and then it was back to square one.

GB: How did you get past all of this?

JD: We actually didn’t. There was this one glorious moment where we were informed that United had finally given in and had decided to pay for everything, but three weeks later I was still getting bills for $30,000 in the mail. So we got back in touch with United and were informed that the adjuster who had made that decision to pay was mistaken, and that his decision was overruled. So we were back on the treadmill again. Then my employer decided to switch insurers.

GB: Did that affect your claim?

JD: I understand why they switched providers, considering how I was being treated. But this just served to make United Health Care even more unresponsive, because now they really had no incentive whatsoever to pay. They weren’t getting those monthly premiums from my employers anymore. There were a few instances where they basically said “You will have to sue us.”

GB: So how long were you fighting this?

JD: About eighteen months.

GB: How did it get resolved?

JD: Well, what happened was that we found out that some adjusters who worked our new provider had been indicted for fraud. Some of them were filing fake workers compensation claims and had been doing so for months, and from what we understood of it there was practically no oversight on the part of the health care provider, which made it very easy for the adjusters to keep this scam going. My employers decided that spoke volumes about the sort of care that they could expect, so they decided to go back to United Health Care.

GB: Why did they go back to United Health Care after the way that they treated you?

JD: Well, there really weren’t all that many other options. There isn’t a huge list of health insurance companies out there. But actually, returning to United Health Care was how my case got resolved. When my employers sat down to negotiate the new terms with United Health Care, they said that the only way they would give United their premium dollars was if they made my case go away. My employers have hundreds of workers, so United decided that the monthly premiums would be a fair trade towards paying the $30,000.

GB: Couldn’t they have come to that conclusion while you were being covered by United the first time around?

JD: I really have no idea what they were thinking.

GB: So in order to simply get your bills paid, your company had to essentially fire United Healthcare and then hire them back?

JD: That’s it in a nutshell.

GB: Have there been any negative after effects from all of this?

JD: Well, my leg is fine, but you have to remember that I was sitting on $30,000 worth of what was basically considered unpaid debt for eighteen months.  They tell you that medical debt is different from credit card debt or mortgage debt, but the banks certainly don’t see it that way.  The people who do credit ratings don’t see it that way. Loan officers don’t see it that way.  Debt is debt is debt. So things are slowly getting back to normal, but when your credit rating takes a hit life does not get easier for you. Another thing to consider is that I had people willing to work for me.  I had the weight of a company with tens of thousands of premium dollars a month behind me, I had someone at the company who made handling the appeals a full time job, and I had a company that was willing to hire an attorney to advise us on how to handle all of this.  The vast majority of people who deal with private health insurance don’t have any of those things going for them, and the insurance companies know this. So as a result you have things like “standard denials,” and the basic attitude of “So? Sue us,” rather than providing the health care coverage that is supposed to be provided.

The difference was that it didn’t go away. It got worse and worse, so much so to the point that after three days I was unable to swallow anything, or even talk. I brought myself into the emergency room and wrote down my symptoms to the admitting room nurse. After waiting for about an hour, they brought me in and gave me x-rays and further pokes and prods. Then another doctor came in and shoved a fiber optic camera up my nose and down the back of my throat, and then I was informed that I had a badly infected epiglottis.

For those of you who don’t remember your high school biology, the epiglottis is a piece of cartilage that forms part of the voice box. It remains inert while you are breathing and talking, but when you swallow food or water it expands to cover the trachea. This is what keeps food from going down your windpipe.

Mine was swollen in place, and the doctor told me that it was the medical equivalent of a garage door being rusted shut. They put me to bed, gave me extremely powerful intravenous antibiotics, and fed me jell-o, broth and tea, and I stayed there for three days.

What is important to note here is that at the time I did not have health insurance. It wasn’t a matter of irresponsibility on my part. I wanted health insurance, but I simply couldn’t afford it. Not on a substitute teachers pay.

The initial bill for my treatment was $10,000. The hospital allowed me to plead “financial hardship,” and lowered the bill to $7,000. The bills took me about two years to pay off.

What makes this story interesting is not necessarily my past illness, but rather what happened about a week ago. I was down in Richmond, Virginia visiting some friends, and I ran into a person I went to college with. We reminisced about old times for awhile, and then he mentioned that he had just gotten out of the hospital. When I asked him why he was in the hospital, he asked me if I knew what the epiglottis does.

It turns out that my friend had the exact same illness, received the exact same tests and treatment, stayed in the hospital for the exact same length of time, and was even fed the same jell-o, broth and tea diet. I knew that my friend had a good job that provided him with health insurance, so I asked him what his out of pocket costs would be, and he told me that it was going to cost him $7,000.

I asked him if he had bad insurance, and he told me that he had chosen the most expensive coverage that was available under his company health plan. The problem was that the insurance company didn’t agree with many of the tests and were refusing to pay for them. They also claimed that my friend was kept in the hospital a day longer than necessary and they were refusing to pay for that as well. His employers were filing appeals and were doing everything that they could, but my friend was not optimistic. He was weighing his two options, which were depleting his savings to pay the bills or getting a second job on the weekends.

To recap, my friend and I had the exact same illness and got the exact same treatment. I did not have insurance, and he did, yet the illness cost us the exact same amount of money.

It was an interesting time to have that particular conversation with my friend, considering that at the time of this writing, President Obama is attempting to move forward with health care reform. Opponents of his attempts are painting a very dire picture, claiming that any reform will end up ruining American health care by forming a huge, inefficient government run bureaucracy.

One of the many vitriolic right-wing radio hosts described efforts at reform as “…government telling us what doctors we can see, which treatment we can have, and what pills we can have.” That seems like nothing more than a description of the status quo.

Have you ever tried to see a doctor that was out of your network? If your treatment isn’t refused outright by the doctor, your insurance company will probably refuse to pay for it. Right now it isn’t the “government telling us what doctors we can see.” It’s the insurance companies.

Considering how my friend was treated by his insurance company, the idea of “government telling us what treatment we can have” doesn’t seem like much of an issue. Anyone reading this can have any treatment that they want, but the prospect of their insurance companies actually paying for that treatment is probably fifty/fifty at best. Actually, seventy/thirty is probably more accurate, considering that my friend had to pay $7,000 out of a $10,000 bill.

And as far as “government telling us what pills we can have,” I actually went into get a prescription filled about a year ago, and I expected the price to be about $10. It turns out that it was $210. When I asked my insurance company why, the answer was because the prescription that I needed wasn’t on the pre-approved list. I asked to see the pre-approved list, and basically that list contained medications that were all old enough to be sold in generic form. So under my insurance company plan, they will pay for any pill, so long as it isn’t the newest and best medications. In order to have that sort of coverage, it would have cost me an extra $75 a month.

Everyone is still taking a look at how this health care reform is going to play out. President Obama seems to be taking the tactic of “let them legislate,” which means that he is perfectly fine with Congress and the Senate batting around ideas until a suitable compromise is reached. While that is all well and good, you have to wonder what good health care reform would be if there was no insurance reform to go with it. Because right now, insurance isn’t “coverage” as much as it is a “coupon.” In the case of my friend, he thought he had insurance, but what he had was 30% off.

We currently live in a country where anyone who gets sick can go broke, regardless of whether they have insurance or not, and that seems much more frightening than getting government involved in health care.

“Small business owners like Chris and Becky Link in Nashville are also struggling. They've always wanted to do right by the workers at their family-run marketing firm, but have recently had to do the unthinkable and lay off a number of employees - layoffs that could have been deferred, they say, if health care costs weren't so high. Across the country, over one third of small businesses have reduced benefits in recent years and one third have dropped their workers' coverage altogether since the early 90's.”

It doesn’t take much to find the flaw in the system for both the doctors and the small business owners. The doctors’ waste precious hours during their working days either trying to get paid by the insurance companies or explaining to their patients why the insurance company won’t pay for services, and the small business owners have to either cut benefits or lay people off because the premiums are so high.

And according to President Obama, it isn’t just the small businesses that are struggling with premium costs:

“A big part of what led General Motors and Chrysler into trouble in recent decades was the huge costs they racked up providing health care for their workers; costs that made them less profitable and less competitive with automakers around the world.”

For all the people who are against government involvement in health care, the constant refrain seems to be “I think health care decisions should be between you and your doctor, and no one else.” The implication there is that if the government gets involved there would be some faceless bureaucracy telling you what treatment you can have, which doctor you can see, and which prescriptions you can have. It is very difficult for us to see how that differs from anyone with your average insurance plan.

If you think the government is a faceless bureaucracy, try getting in touch with your insurance company for anything other than paying your premiums. If you think that you can see whichever doctor you choose, see what happens when you try to go see a doctor who isn’t part of your insurance plan. If you think that you can have whichever pills you want, see what happens when the pills you need aren’t on the approved list of your insurance company.

It seems that many of the folks on the anti-reform side believe that there is something profoundly unpatriotic about the idea of getting sick without going broke. But we believe that there can be no health care reform without insurance reform. Insurance is the only business in America (and possibly the world) where you pay an arm and a leg for services that might be rendered, but only if those services aren’t too costly and inconvenient for the people providing them. Plumbers don’t work like that. Carpenters don’t work like that. In fact, if anyone else worked like that they wouldn’t be in business at all.

If you were a fly on the wall over at one of the more expensive offices on K Street, you would see insurance company lobbyists using every number in their considerable rolodexes, and you would hear these lobbyists urging members of Congress to either kill health care reform completely or to fill it with compromises that either render the reform meaningless or make life easier on the insurance companies. Chief among these compromises is “caps,” which is a set limit on the amount of compensation that victims of medical malpractice can receive. They are probably contending that if only there were a limit on compensation, then health care costs would immediately drop like a stone. This is fiction.

According to the Congressional Budget Office (via the New York Times:)

“The office estimates that caps on damages would ultimately reduce malpractice premiums for medical providers but would have a “relatively small” impact on total health spending, reducing it by less than half a percent.”

As usual, the main concern of the insurance company is profits. And if they can maximize those profits by connecting two completely unrelated things (malpractice premiums and healthcare costs,) why wouldn’t they? These caps have maximized insurance profits in Texas, Nevada, and countless other states. But we can’t help but notice that people in these states are still paying just as much as they used to.

To learn more about malpractice issues, please read our malpractice page, or read about our malpractice lawyer, John Sellinger, or view his malpractice video on Utube, or file a free legal consultation with Greenberg & Bederman.