Guaranteed Healthcare

In August 2007 my finance, Karla, was injured when a ceiling fell on her at a local restaurant. She was taken to a local hospital emergency room by ambulance where she was seen ultimately by a physician and a CAT scan was completed and she was released. After a couple days and she was feeling worse she saw her physician and she set up an appointment with a neurosurgeon. It was found that Karla has 2 ruptured discs in her cervical spine that will ultimately require surgery to correct.

The insurance company for the restaurant contacted us to tell us they did not feel they had any liability but would pay $1,000 to help cover her expenses. We then turned the claims over to Karla's insurance (a self insured plan through Fishback Financial in South Dakota).

Karla also has a severe underlying medical condition (pulmonary hypertension and chronic obstructive pulmonary disease (she has never smoked)) that the neurosurgeon ask that she see her pulmonologist to get clearance for surgery, her local pulmonologist asked that she go to see an expert on pulmonary hypertension at the Mayo Clinic in Rochester MN which we had seen in the past when the disease was diagnosed. For the first few bills that came in her insurance paid but after they started getting more bills they denied coverage, in fact they asked for and received refunds from the health care providers for the bills they paid.

Currently we are under threat to be turned over to collection for the unpaid bills. The ambulance company is the most threatening. During all of this Karla has continued to see specialists at the Mayo Clinic to treat her pulmonary hypertension, she has also had an adverse reaction to sleeping medication she has used in the past before the accident that landed her back in the emergency room because she passed out and had symptoms of a stroke, this landed her in the local ICU for a night while a stroke diagnoses was considered. She had also seen her physician for other minor medical issues like a possible kidney stones.

Her insurance has refused payment on all these claims. They claim all are related to the original accident. We contacted our Senator, Tim Johnson, and he had the Dept. of Labor Employee benefit office in Kansas City contact us. The bad news is that the Federal ERISA laws allow this, although the person we talked to and her supervisor state that they had never seen such a restrictive plan and needed to look into it further. We later received a letter from the administrator of the Federal program written to Senator Johnson that said what they were doing was legal but again they had never seen such a restrictive plan. The DOL in KC staff person suggested we get an attorney, which we have done. To date after pressure from our attorney the plan said they will pay some expenses but as of yet have not paid. The third party insurer still claims they have no liability. We are left in a medical insurance limbo. This all boils down to the fact, we both have health insurance, but they will not pay because the Federal ERISA law does not require subrogation. A friend of ours injured in the same accident is on Medicare (he is retired) Medicare has been easy to work with, have the providers submit the claims and they will pay. His problem arose when the health care providers refused to submit the claims to Medicare because they want to collect more money from the third party insurer. and they are asking that he make payments.

Our system is worse than broke, it provides a false sense of security, everyone is happy to collect premiums they just do not want to pay out benefits. To date our medical bills remain mostly unpaid and approaching $25,000, our neurosurgeon says surgery will be required to correct the spinal cord compression and that the surgery could range from $100,000 to $150,000 if performed today.

If we have the surgery and the insurers refuse to pay it will wipe out all of our savings. We will have to sue the third party insurer to recover payment for her insurer and they refuse to pay their share of the attorney fees for the recovery if there is one. The best case scenario that we see is that we pay our attorney to recover their costs, and we will not be reimbursed for our expenses and probably be out $10,000 to $20,000 according to our attorney, worst case is they continue their hard stance, we wipe out our savings and what once looked like a future retirement will now be working well into retirement age in an attempt to recover lost savings and maybe even bankruptcy.

I'm sure you have heard from many with worse stories. The frightening part of our story is that we are both "fully insured". We would have never believed that we would be in this situation. If this could happen to us what is in store for the remainder of the population who feel the same way we did before the accident? And what about the folks with no insurance?