Urgent - N/A Medical (system) advice needed

gkainz

gkainz

Final Approach
Joined
Feb 23, 2005
Messages
8,401
Location
Arvada, CO
Display Name
Display name:
Greg Kainz
Guys 'n gals ... this year has just continued to pile on the crap ... haven't flown in a year and didn't renew my medical, as the stresses kept coming. Here's the latest, and one I really hope someone may have some suggestions on working through.

Our grandson was born this March, premature, and had suffered developmental issues in utero. He was born at 35 weeks but measured equivalent to 32 weeks. He was diagnosed with West Syndrome a couple of weeks ago, and last week further diagnosis revealed Cerebral Palsey, resulting from trauma (low blood circulation or low O2) at or before birth. He was prescribed a med to control the seizures that slowed them down but did not stop them.

He was admitted to the hospital yesterday and prescribed a bigger gun med, corticotropin (ACTH) to stop the seizures. This drug requires a few days of hospitalization to monitor blood sugars and blood pressure; two dangerous side effects (among many others).

The kids just found out moments ago that their insurance only pays for generic drugs. This drug is not available in generic, and a month's supply (anticipated dosage required) will be $75,000. We and they are at wit's end and looking for ideas...

Ironically, the insurance will cover the drug if Zach stays admitted to the hospital for the whole course of treatment.

The hospital is contacting the drug manufacturer looking for help but no answer yet.
 
First Greg I'm very sorry to hear your going through all this crap. Also sorry to hear about your grandsons condition. Here are a few ideas.

1) There is a company in PA called Health Answers , you can find them on line. They act as Advocates for folks with thier insurance carriers

2) We went through a similar problem with my father in law when he was very ill with cancer. He got a fungal infection and the med that he needed just came out in pill form. Previously it was IV only. The insurance company would pay for the IV treatment because it was initally less expensive thing is he had to be hospitalized to get the IV so IV plus hospital was thousands more than the pill but they wouln't pay for the pills. GRRRRRRRRRRR go figure.
Thankfully the infectious disease doc was a real proactive guy and read the riot act to the Insurance carrier. perhaps you can ask your grandsons physcian to do the same.

3) PM me your grandsons name and I'll add him to my prayers at Synagogue this weekend.
 
Greg, your grandson and your whole family are included in my prayers. Be kind to yourself even as you try to lighten the load for your kids.

-Skip
 
Update ... this afternoon the kids were told that their insurance company was NOT going to pay for Zachary's hospitalization nor the medication Acthar. I don't know if they (insurance) hinted, suggested or outright stated that they were also denying claims for charges incurred to-date for hospitalization and meds, but did say that they would not continue to pay for either one. The kids were facing over $200k out of pocket charges, and another $75k for immediate future charges for meds.

So, how's that for a voice message just prior to walking into a meeting? Yeah, like getting kicked in the gut.

Came out of the meeting later in the day to another voice mail saying the insurance company and drug company had capitulated (after a serious phone session with the head of neurology from Children's hospital) and between the two of them, prior hospitalization and meds charges were covered, remainder of the meds required were covered (drug co comp'ed, reduced, discounted, whatever, the obscene cost of the meds down to something reasonable and insurance agreed to cover the balance) and as soon as the meds are delivered to the hospital and given to the kids, Zachary could be discharged and monitored via home health care.

Whew, what a relief. Now, if we can just see the seizures gone. They're subsiding, and we thought completely gone over the last 36 hours, but this evening he had 30 minutes of spasms, altho less intense than previously experienced.
 
That is a HUGE relief Greg... I'm glad that they got it worked out. Zachary and your family will be in my prayers that the seizures will stop.
 
That's terrific news. I'm a little disappointed that the insurance company flip-flopped like that, though... If they could work it out in several hours, why didn't they just do it?
 
TMetzinger said:
That's terrific news. I'm a little disappointed that the insurance company flip-flopped like that, though... If they could work it out in several hours, why didn't they just do it?
Click to expand...

[cynicism] Because they were throwing it against the wall, to see what stuck.[/cynicism]

When Celia was pregnant with Tomster, her insurance at her place of employment (new insurance) covered pre-natal stuff like a blanket, no problems.

But, when he tried to punch his way out 11 weeks early, Celia was admitted to the high-risk-pregnancy wing and told she was not goin' nowhere until she birthed a baby boy. They were hoping to keep him in utero for a couple of weeks, and it worked out to four full weeks (about which the docs were much pleased).

So Tommy's born, and immediately admitted to the NICU with new issues (his weight was good, even though he was still early), and Celia came home after a couple of recovery days. In the mail box when we got home, was a stack of about forty letters, each informing us that a particular charge for the hospitalization had been erroneously paid, because they had decided that the pregnancy was a pre-existing condition. The charges they wanted paid back (they included postage-paid envelopes, thoughtfully) aggregated some enormous sum, well over $100k IIRC and certainly more money than we had at the time.

Since we were busy worrying about keeping our son alive, we sort of let it just wash over us, but turned it over to the senior partner at the firm where I worked, who was well-acquainted with the law on-point (in Texas, no physician DX means no pre-existing condition, not same in some other states).

Insurer finally sent a letter stating that they would, "...as a one-time, non-precedent-setting exception, allow the coverage." Which was fine with us, since we were having this kid but once anyway!

I have often wondered how many people, lacking the ready, eager and knowledgeable resources I had at my disposal, would have just thrown up their hands and gone bankrupt. Many, I suspect, and that is what I imagine the carrier was shooting for.

Collect premiums, deny claims- some say this is the true business model for insurance.
 
Greg, I'm glad the insurance company came around and you've got the help you do in hospital administration. His name remains on my list.

Spike, I can't even comprehend anyone being so stupid to refer to pregnancy as "preexisting" so they don't cover difficult prenatal care. It boggles the mind.
 
Greg I am glad it worked out. I am still going through a lot with my mom's medical bills and getting the ones that should be paid, paid by the insurance, the rest are being reffered to the estate which is now bankrupt. I get great joy telling the a-holes at several places to f-off (in a nice legal way of course). Welcome to managed health care in America.
 
SCCutler said:
Collect premiums, deny claims- some say this is the true business model for insurance.
Click to expand...

Spike... after spend too many years of my short life working for a health insurer (that was far more above board than what you describe above), I can tell you that with most carriers, this is sadly the norm.

Greg - I'm glad things turned out OK for your family. Jessie and I will keep them in our thoughts.

Cheers,

-Andrew
 
You must log in or register to reply here.
Back
Top