Death PanelsI was about to write a post about the following situation, but I'll just do a comment, instead- it's on-topic.
Death Panels already exist (though I generally avoid inflamed rhetoric, this Death Panel meme needs to be converted to good use) in the private insurance industry.
I believe all of the following statements, though I haven't verified all of them personally, are accurate:
I know a man who has been battling a rare blood cancer diagnosed as histiocytic sarcoma (HS). He was a wife and young kids. His doctors at MGH, supported by second opinions at Dana Farber and beyond, agree that a stem cell transplant is his only hope for long-term survival.
He was scheduled to be admitted for the transplant on 10/19, but his insurance, Blue Cross Blue Shield (BCBS), has denied a second appeal for coverage of the procedure because it is not a “medical necessity” and cites “lack of evidence documenting the efficacy of this treatment.” Because of the rarity of this disease, such evidence simply doesn't exist for HS, but there is one known HS survivor who is now living 11 months after his stem cell transplant. Without the transplant, he will not make it many months past his next disease progression. There is a small window of opportunity to perform the transplant now.
This man's wife is pursuing the following list of actions. If anyone reading this has any other leads, contacts or ideas, please let me know.
1. They are submitting a consumer appeal to BCBS – File this by Friday at the latest. For terminal illnesses, BCBS must reply within 5 business days. While they are considering the case, it would put some pressure on them to receive inquiries from the press or BCBS upper management. Doe anyone know anyone with media or PR contacts? Is there a cancer story in the works that this could be part of?
2. They are submitting letters to Senator Kirk's office as well as Congressman Tsongas's office. Doe anyone have contacts in those offices (or others we've not thought of) who could bring attention to our case?
3. They are looking for an attorney experienced in successfully overturning insurance denials. Referrals would be useful. Area of practice would be “health insurance denials.”
4. If the BCBS consumer appeal is denied, the next step is MA's Office of Patient Protection. They will conduct an external review. Does anyone know anyone in that office? Or have any experience with the external review process?
5. They are in contact with Coakley's office. They said the family should come back to her at that point if these other avenues are not useful. I'm not sure what the attorney general's office would do, but she said to call again.
Beyond this, has anyone reading this had experience fighting health insurance denials? It would be useful to know which steps might be more favorable towards this case.
Also, where there are grey areas in the interpretation of the policy language, what other factors are most persuasive to the insurance companies?
Now, I have BCBS insurance myself, and have always been quite happy with it- I'm not trying to smear BCBS, I'm just trying to get this family help (and point out the need for health insurance reform- it's not health care reform, folks. it's health insurance reform). My father died of a rare disease when I was 6, so I get particularly upset when I know of other children facing the same outlook.