Isn't this exactly what health insurance is for?
Yesterday evening I got to meet Gracie's friend Riley and her family from Colorado. Riley is an adorable little red-head with pretty eyes. She was so cute. She showed us her bellybutton, her nose, ear and toes. Very smart!
After speaking with the family, it sounds like they've had a hell of a time dealing with this illness. Riley has been getting ERT treatments for a while, but their insurance company (Sun Life out of Boston) has not yet approved the transplant procedure. Given that two other kids are at the RMH with the same disease and have been approved by their insurance company, it's that much harder for the family to swallow. Sun Life is citing a stop/loss policy condition or something as the reason to not pay. What I thought was strange is that Sun Life hasn't committed one way or the other. They say they *might* cover it, and they might pass the bill on to the dad's employer. I can't quite figure that one out.
Riley's dad has clearly been around and around with them, and the docs and nurses at Fairview/Univ of MN have been using everything in their arsenal to get them to commit to covering. It's just such a shame, because this is exactly what insurance is for. It's supposed to kick in when something totally unexpected and astronomically expensive happens. That's why we pay into in, even when nothing happens over the course of 1,2, or even 10 years. Yes?
Anyway, the insurance company says that the treatment is experimental, ever though it has been done for 20+ years. But because there is a clinical trial associated with it, they call it experimental (regardless of whether they enroll in the trial). I wish I could help them. Maybe I could pull a list of a bunch of other ongoing clinical trials. I wonder if they cover drug-coated stents for heart disease? I'm sure there are countless trials underway for other established treatments for more common conditions like heart disease, asthma, even erectile dysfunction. I bet they cover those treatments. It's a numbers game. The thousands of Sun Life members who have those conditions would run them out of business otherwise. Just because a condition is really rare, doesn't mean that treatments for those diseases are not proven and established. But because it's so expensive and there are so few members impacted, they can get away with screwing you.
If anyone know anything about insurance companies, how they work, how to respond to them, or has any recommendations for Riley's family, please let me know. In the meantime, keep her family in your thoughts.
I think Dr. Orchard sent a letter to the Boston Globe. If and when it's published we'll share it with you.
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2 comments:
GRRRRRRRRRR!
What are the repercussions of a "maybe?" If they did bounce the bill back to Riley's Dad's employer, could they fight over it then? Of course, uncertainty about payment might prevent the hospital from doing the transplant at all...
Will Fairview do the transplant without certainty as to who is paying? I'm envisioning the insurance company declining to pay, the family getting the bill, and perhaps some charitable organization picking it up, in full or in part?
I admit my understanding of all this is a little unsophisticated, but for crying out loud! I think this would be a nice local-paper do-gooder article for someone with money to give, and also a great nasty-gram for Sun Life!
Sarah- on this one, let the family know that Dad should contact his HR department ASAP if they haven't already done so. Also, they need to find out if their coverage through his employer is Self Insured or fully insured. If it is fully insured they need to take it to the state Dept. of Insurance in the state where they are insured (home state) and get them involved. If it is self insured, then taking it to the company and the dept. of labor will help to get results too. If they need to talk with someone who has insurance knowledge just let me know and I will pm you my phone number on Life's Lounge and we can go from there. I would be happy to try and help as much as possible.
Patty (from BBB)
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