Our Causes and Charities

Your voice is not being heard about the Patients' Bill of Rights

PHILADELPHIA INQUIRER Monday, February 19, 2001

HMO reaction to a cost-saving request: Brace yourself        By Dina A. Leacock

My husband and I have been members of a health-maintenance organization for years. We have always been happy with the services provided and the doctors we chose. That is, until now.

Don't get me wrong. I still don't have a complaint about the doctors and actual services. My complaint has to do with bureaucratic nonsense that borders on the absurd.

I've had knee surgery, twice. And someday I'll need to have it again. In the meantime, I wear a metal knee brace for all activities. I dislike the brace, but if it keeps the surgeon away, I'll use it.

Three years ago, I had my latest operation, and my insurance company paid for the brace. My doctor told me that losing some weight would help my knee, so I lost about 50 pounds.

Now my knee feels better, my clothes fit better, and I eat a healthy diet. Unfortunately, my brace doesn't fit anymore. My doctor said I needed a new one.

Much to my surprise, my insurance company turned down the request. The person who reviewed my case expressed regret but said a brace wasn't covered under our policy.

If it isn't covered, then it isn't covered. But I called my insurance company anyway to explain my situation. Without the brace, I fall down. I had already fallen twice, once so hard that I had to have X-rays and return to the orthopedist.

I explained to the person on the phone that the brace wasn't a sports luxury but was used to save me from an expensive operation. I tried to explain that denying the brace would cost a fortune in doctors' bills, surgery bills, and months of rehabilitation bills.

The woman on the other end of the line didn't see it that way. "There is no one to talk to. Your policy is clear: The brace is not covered," she said.

I slowly explained that I would have to have another operation without the brace and that the insurance company would have to cover it.

"That is correct," she said. "The operation is covered, but the brace is not."

"Are you telling me that the HMO would rather pay thousands of dollars on an operation rather than a few hundred on a brace?"

"Yes, if that is what your policy will cover."

"The company would rather force me to have surgery than prevent it?"

She sighed. "Well, you could buy the brace yourself and not have the operation. Then we both would be happy."

"Not very likely," I snapped.

I went through the conversation several more times with several other people and got nowhere. No wonder so many health-insurance companies have gone belly up.

I'm going to file a grievance, but I don't expect to hear from a human at the top. It will just go through the paper mill and get filed away somewhere, and someday I'll get a letter explaining just what is covered and what is not.

The insurance company will not give me any options, something I tried to give it. I tried to save it money and avoid extensive medical bills. If only someone at the insurance company had the ability to listen, to think, to hear what was really being said, rather than just reading from a policy.
 
 

--------------------------------------------------------------------------------
Dina A. Leacock, who works at an agency that serves senior citizens, writes from Medford.