A father wonders why his insurance company denied paying for his daughter s medical procedure even after an appeals process compelled the company to reimburse costs for similar treatment for his son, who shares the same condition. Troubleshooter Sabina Kuriakose tells you why you may not have to take no for an answer from your insurance company.
Twenty-five-year-old Hillary Eisenberg suffers from degenerative disc disease. As she hit her mid-20s, she was faced with debilitating back pain.
“The pain was a 15 on a scale of one to 10,” she described.
Her brother, Eric Eisenberg, suffers from the same disease, and three years ago he had to have surgery. Their dad Joe weighed the options for Eric’s treatment. Doctors told him standard treatment would be spinal fusion, but the surgery would have consequences.
“It limits your mobility forever and it causes the discs above and below where they go to have problems later on,” explained Joe.
Instead, the family opted for cutting-edge artificial disc replacement surgery at Yale-New Haven Hospital. According to Joe, the family was told the new treatment was the best option for Eric, because it meant a faster recovery and smaller chance of side effects than spinal fusion. Everything was all set to go, until the Eisenbergs got some disappointing news.
“About two weeks before the surgery for Eric, which was in December of ’11, I got a letter from the insurance company which said the surgery was considered experimental and investigational and therefore not medically necessary, and that they were not covering it,” recalled Joe.
He was adamantly opposed to spinal fusion for his son and managed to scrape together the $60,000 needed to pay for Eric’s disc replacement surgery.
“I got it together somehow and I brought it to them," he said. "The surgery was done, completely successful. There’s no recovery except for the wound where they go in."
But the insurance battle wasn’t over. Joe filed appeal after appeal asking his insurance company, Assurant Health, to reimburse him.
The state sent the case to an outside review board, and Joe won.
“One of the reasons that it was reversed for my son is because of his age and how detrimental it would have been to him for the rest of his life,” explained Joe.
Now Joe is right in the thick of round two with his insurance company. Daughter Hillary needs the same exact surgery for the same disease, but Assurant declined to pay for the disc replacement surgery.
“In Ms. Eisenburg’s case, same thing. Same condition, same requested procedure, same denial," said Demian Fontanella, General Counsel for the Office of the Healthcare Advocate. "So at this point we’re waiting to see if the external reviewer will also agree [that] yes, this is the most appropriate form of treatment and it should be covered.”
The OHA is helping Joe file an appeal with Assurant in Hillary’s case. The family already paid $70,000 out of pocket to ease Hillary’s pain in November.
“[It feels] better than new. My pain is zero, it’s nonexistent,” said Hillary more than three months after her disc replacement.
Joe is dismayed that the insurance company refused to pay for her surgery.
“It’s not even believable that they could put you through it twice. I understand the first time, but when I have this [appeal] that’s final and binding on my son and my daughter needs the exact same thing and they turn it down, it’s amazing they can get away with it,” he said.
“Experimental investigative treatments are very much like the new technology,” explained Fontanella. “Companies are hesitant at minimum to actually approve those treatments because technically they’re still in the investigative phase.”
Joe wants to share his family’s story to help others. He’s grateful he could at least front the cash for his children’s surgeries, but he understands that most people could not.
The Office of the Healthcare Advocate says that’s where they step in. OHCA helped research Joe’s case and argue on his behalf. Fontanella told the Troubleshooters his office has a 60-70 percent success rate on its appeals.
“In a lot of cases it’s simply a matter of getting the medical record put together and plugging it into the criteria piece by piece, line by line,” he told us.
That said, Fontanella explained that insurance companies have the right to deny experimental procedures. He said those types of treatments can be so new that there may not be many studies or scientific research conducted on possible benefits or risks.
We reached out to Assurant Health and a spokesperson sent us this statement:
"Due to privacy protections, Assurant Health cannot discuss or comment on specific circumstances involving any of our customers.
"Our process is to review each claim individually. We are committed to following claims practices in accordance with all applicable state and federal regulations, as well as following industry and accepted medical standards.
"In the event a customers’ claim is denied, we communicate directly with them and provide our customers with information regarding the appeals process, including their right to request an independent third party claim review by the State of Connecticut Insurance Department."
Joe and his family are now waiting for the results of their final appeal.