My dad was a doctor. Dad told me on several occasions that if I ever came home and said I wanted to follow in his footsteps and become a doctor too, he’d lock me in my room for seven years. One of the reasons for this was because he hated dealing with insurance companies. I vividly remember going out to the mailbox one day and finding a letter addressed to Dr. Farquhar, with a very angry note written on the front of the envelope: PLS LET THE DR READ THE LTR. I asked what this was about, and Dad said insurance was refusing to pay for a patient’s treatment. He said it happened a lot.
Now I’m 33, and my insurance was refusing to pay for treatment my wife needed. The best-case scenario without her medication would have involved numerous hospitalizations. The worst-case scenario? Coma or stroke if a lot of things went wrong. If everything went wrong, death wasn’t out of the question.
Here’s what I did about it.This isn’t exactly how I wanted to tell everyone, but my wife is pregnant. She’s also diabetic, and diabetes and pregnancy aren’t exactly the best combination. It wasn’t long before she was complaining about nausea. That wasn’t anything new; she can get bad nausea at times even when not pregnant. We try to keep a decent supply of Emetrol (or a generic version) on hand because of it. But we didn’t know if it was safe for her to take that while pregnant, so I suggested she ask her doctor. The doctor put her on a generic version of Zofran, a powerful anti-nausea drug.
The difference was like night and day. Without the drug, she couldn’t be up and around for more than 3-4 hours at a time. With the drug, she could function almost normally.
But after a month, the party was over. The insurance company refused to pay for the drug any longer. The doctor protested, but to no avail. So the doctor prescribed alternative anti-nausea drugs.
None of them worked.
She started a rapid decline. Within days, she couldn’t keep food down. Four days after that, she couldn’t even keep water down. She went to the doctor, and her doctor sent her straight to the hospital where she was admitted and treated for dehydration and severe morning sickness (I don’t remember the medical term). They kept her in the hospital overnight.
When her doctor visited, I asked him what to do. He said insurance companies do this all the time.
"Let me get this straight. This guy with no education, who’s never seen her, knows better than you do what’s best for my wife?" I asked.
He said he sees this every day, and he’s sick of it.
"So do I need to look into getting a lawyer and suing this company for malpractice?" I asked. After all, there was at least one time when Dad said a patient needed one treatment, and a different doctor decided to do a different treatment and the patient died. The patient’s family, based on what Dad said, sued the other doctor for malpractice. If a doctor can be sued for practicing medicine badly, why can’t an insurance company be sued when it practices medicine badly?
He said if I did that I’d probably end up on CNN and he’d love to see the public pay that kind of attention to the insurance industry, but it wouldn’t help my wife any.
So I asked about buying the drug outright, without insurance. It was going to cost more than $400 a month. That’s outside of most budgets. I probably could have made it work, by making some cutbacks on food purchases, taking on some extra work, and if all else failed, borrowing some money, but it shouldn’t be necessary. This is why we get insurance in the first place–to cover these kinds of expenses.
So I looked into what it would cost to import the drug from Canada. The best price I found was $330–not much help.
I called my boss and told him what was going on, originally for no reason other than to provide justification for why I wouldn’t be at work the next day. But the more I told him, the more apparent it became that the situation offended him too–and not just because I was missing work over it. And that gave me an idea.
If the situation offended him, then it probably would offend the decision-makers at the company too. I decided I needed to talk to my boss and ask if I would be going over his head by talking to the higher-ups about the situation.
He gave me the OK, so I wrote a letter to my employer’s upper management. It wasn’t very long. In point by point fashion, I described my wife’s medical needs, what the doctor had done about it, what happened after the insurance company stopped paying for the drug, and what risks were involved with my wife not getting the treatment that she needed. I spelled it all out in lay terms. I also tried to be very matter-of-fact about it. They didn’t need my opinions on the matter–the facts spoke for themselves. Nobody would want their wife or daughter to have to go through what my wife was going through. And that was what I was counting on.
My letter climbed up the corporate ladder and over to HR very quickly. Not long after that, the HR director had the insurance company’s representative on the phone. Before the day was over, my wife had her medicine, and by the next day, she had a case manager assigned to her.
I believe this is the only approach that would have worked, and this is why:
1. I have an acquaintance who once worked for an insurance company, in the IT shop. He told me the majority of insurance adjustors who make decisions about what the insurance company will and won’t pay for are frustrated people with minimal education (sometimes just a GED) and they get their jollies by overruling doctors. It’s a power trip, and it’s what gives their lives meaning. Calling up the 800 number on the back of the card and complaining doesn’t do any good because it just proves to them how much power they hold. And calling the number and treating whoever answers the phone to a profanity-laced tirade (or even just asking the person where he or she went to med school) really drives home how much power they hold.
2. I’m just one customer and I have no control. The insurance company doesn’t care if I leave, because all they lose is a bad customer. Remember, customers who pay into the system and don’t take anything back out cause profits to rise. Customers who take money out of the system cause profits to fall. And besides that, I have no say in where my company buys its insurance anyway. The only way for me to change insurance providers is to change jobs, and that’s not only impracticel, it’s also very difficult.
What I had to do was to take my case to the people who do make that decision, and appeal to them. Working from the assumption that none of them would want the same thing to happen to their wives and daughters, I just presented the facts and let them come to the conclusion that the insurance company would do the same thing to anyone else in that situation too–including them. After all, they’re covered under the same plan I am. And of course they wouldn’t want that. What I basically did was raise the stakes. The insurance company wouldn’t be sorry to see me go, but what insurance company wants to risk losing a whole company’s business?
3. I kept my cool. By my own admission, to call me a loose cannon is an understatement. If I don’t like something, everyone around me knows it. But I wasn’t going to make any friends by saying "You guys are idiots for choosing to buy insurance from [company x] because they’re trying to kill my wife and unborn child." My emotions and opinions were more likely to make them get mad at me, and I needed them to be mad at the insurance company, not me. So I trusted them to be reasonable, rational people and come to the same conclusion I would when presented with the same seven basic facts.
So that’s how I got an insurance company to let my wife have a drug they decided they didn’t want to pay for.
What a story.
I wish that I had some option like that, but you know how things work where I am. It’s not going to happen like that.
And… congratulations! Really great news. I hope that there are no more complications.
The tactic works if there’s someone high enough in the organization willing to go to bat for you OR if there’s someone near the top who recognizes your name and has a soul.
I like your odds there better than mine were. But pregnancy is a more recent memory in the minds of the people near the top where I am than where you are, and I think that helped me.
As far as the pregnancy, with this out of the way I’m pretty confident. She’s healthy and has good doctors who know we’ll do whatever we have to do
47 million folks don’t have your ability to fight for medication.
Everyone should have insurance and you wouldn’t have to fight.
I agree with you. The reason I’m not self-employed is because of the limited options for insurance for my wife because she’s diabetic. Never mind she takes better care of herself than a lot of people who aren’t diabetic. The majority of providers see the "D" word and won’t look past it before throwing her in the "uninsurable" pile. The options that are left make us jump through a lot of hoops.
I don’t know how you solve it. A government takeover brings a new set of problems. Maybe the answer is tighter regulation. But the insurance industry has a lot of money to use to buy votes, and that’s a big obstacle to overcome.
The approach some states are taking where they require you to have insurance doesn’t solve the problem unless they also force insurance companies to sell insurance to you at a reasonable price.
In our case, during an 8-month interval where I was a contractor for a company that didn’t provide insurance and we couldn’t buy private insurance, the insurance agent who takes care of our auto and homeowner insurance told us about a state-provided plan. It was really expensive and didn’t cover pre-existing conditions for a year. It wasn’t ideal but at the time we couldn’t find any better options either.
Back in the early 1990s when it looked like the Clinton plan was unstoppable, at least one alternative plan based on the plan Congress gets surfaced. Unfortunately when the Clinton plan got derailed, the GOP abandoned the alternatives too.