Although the identifying details of this story — including the name of the insurance company — have been changed, the story is 100% true.
For the past ten months, the Rofeh Cholim Cancer Society (RCCS) has been subsidizing a full health insurance policy for a 33-year-old father of three. Unfortunately, his disease spread to the point where he needed a bone marrow transplant to stay alive.
The medical experts advising RCCS unanimously agreed that his best chances were to have this life-saving operation performed at the Clarian Transplant Center of the Indiana University School of Medicine. The problem was that “ABC Insurance Company” refused to sanction this half-million dollar procedure, as it could be performed in New York for substantially less money. The patient’s family, after doing much research, insisted that this life-or-death operation be performed by Dr. Lawrence Einhorn in Indiana, as his record of success was the best in the nation.
So the battle began.
When ABC adamantly refused to authorize the transplant in Indiana, RCCS insurance advocates challenged the insurance company’s administrative unit, proving that, contractually, the patient was entitled to nationwide care and that they had no basis for limiting his medical options. When the company saw that they were up against a formidable opponent, they backed down and agreed to cover 70% of the costs. Since 30% of $500,000 would still place a substantial burden on the patient and his family, RCCS countered that the Indiana transplant center was within the ABC network and that the patient was therefore entitled to 100% coverage.
The ABC representative replied that ABC had made an administrative decision that the contractual agreement did not cover this specific case, and that they would not back down.
The knock-out punch was finally delivered: RCCS demanded a reference from the contract agreement in support of ABC’s position. Of course, ABC was not able to provide ANY reference, and so they finally capitulated and agreed to cover 100% of the costs.
The transplant took place a few days ago in Indiana, and we wish the patient a speedy recovery.
(YWN Desk – NYC)