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The
only prognosis worse than "poor" (my current prognosis) is "fatal."
Granted Social Security Disability during July, 1999.
After returning to work, I requested an Americans with Disabilities Act (ADA) accommodation to modify my work requirements because of my limitations. The company requested specific accommodation information from the doctor. Based upon my normal work day and previous performance appraisals, he recommended that interpersonal interaction (IPI) be limited. Instead, the IPI requirements escalated. Could there be a correlation between my sudden performance degradation, probation, and my aggressive pursuit of costly health benefits?
I requested a complete audit of the treatment/reimbursement for the doctor. I also requested a copy of the complete health benefit language so we could more easily determine and understand the denial reasons. Even though we had requested from both "False Hope" and MRG a "reason for denial" in language we could understand (as required by 29USC, ERISA), we were still answered with the same cryptic computer codes. They never cited the specific plan provision that would support a denial.
Interestingly, the more I pressed for my medical benefits, the greater the performance-based stress increased.
While still at work, I contacted the Director of Human Resources (Lucy Finger), the Employee Benefits Manager (Sherri Hancock), and the Plan Administrator (Linda Farina). I outlined the high level of arrearage to the doctor, and relayed his treatment plan. It requested a GUARANTEED approval for IV antibiotics. The guarantee was needed because neither the doctor nor I could absorb the cost beyond the what is already uncollected.
To date, MRG has ignored and left unanswered my guarantee request. They still have not complied with the request for complete plan language; the 30 days expires 9/5/98. (Received 8/28/98).
Instead, MRG has requested a complete record audit by "False Hope", and "oh, bye the way, could the doctor provide a complete copy of the medical record? We'll even pay for it, if the costs are reasonable."
This I resisted. I told Linda Farina rather than duplicate previous efforts (I have return-receipt-requested documentation concerning prior deliveries), I told her to have "False Hope" send a list of information they "think" they are missing. From that list, we will refute (based upon prior delivery) or comply.
While all this was going on, I developed vision problems, facial numbness, and spasmodic shakes. The rapidity of onset, and the escalating severity made the doctor order Visual Evoke Potential (VEP) testing, an electroencephalogram (EEG), and an ophthalmic exam.
The ophthalmic exam revealed a major change in eyeglass prescription and "mild" cataracts. The VEP found Optic Neuritis (ON), the EEG was within limits. Medical literature suggests that 50% to 100% of ON sufferers go on to develop other Multiple Sclerosis (MS) symptoms within 2 years.
The vision problems, facial palsy, and spasmodic shakes (mimicking Parkinson's Disease) increased to the point that I was placed on a cane (for ambulatory stability) and Baclofen. Baclofen is used to treat Cerebral Palsy (CP), MS, and/or spinal cord injuries. I was also placed on STD again.
Since the second STD occurred within 31 days of the prior STD, Linda Farina determined that they were the "same or related," and caused my pay to be reduced from 100% for 4 weeks to 55% because of STD continuation. When I questioned her about how "HSV I, cellulitis" could be construed as "same or related" to the disorders that were listed on the most recent STD request:
Lyme Disease
Linda then relayed my concerns to MedEval for determination. If MedEval determines they are not the "same or related," then they'll gladly cut a manual adjustment check.
(Received word on 9/7/98 that it was determined the STDs were NOT "same or related." Received manual check 9/10/98, with reduced STD pay to start again on 9/15/98).
Meanwhile, the doctor sent a formal letter to MRG's Director of Human Resources (Lucy Finger), outlining my medical history, the obscene level of arrearage, a treatment plan, and formally requested a GUARANTEED approval. He stated that prognosis is poor without the recommended treatment. To date, the doctor's letter has not been acknowledged. (Acknowledged August 31, 1998. "We don't pre-certify this stuff. We evaluate retroactively when you do it.").
I finally received "False Hope's" "list" of information they "think" they are missing. Here's the "list":Please provide "Complete clinical documentation including the initial history and physical, office notes, lab reports, tests and results for all services rendered from 02/09/96-12/22/97."
Dammit, they already have the information, multiple times! We still do not have the complete plan language (received 8/28/98) , nor do we have denial reasons written in a language we can understand, nor the plan provision(s) supporting the denial.
The flurry of e-mail, letters, and faxes finally got something going. JC of the "False Hope" Claims Department sent a position letter. This generated additional passing-the-buck correspondence, as listed in the following links:
1. By their own admission, the reviewing doctor only had "some" of the correspondence.
2. By their own admission, the lawyer only reviewed the Plan for legal compliance, and did not address my concerns about what was "understandable" by me, nor what I considered "specific".
At this time, I am on STD, a cane, and Baclofen, to keep me from hurting myself. No other treatment for ON, LD, or the MS symptomology. I can't blame the doctor. He's already at a five figure level in the hole for my treatment. He can't absorb anymore cost (he has 17 other patients whose health plans have "False Hope" as the TPA, with identical non-reimbursed results: this includes an arrearage for my wife Karen's treatment) , and neither can we.
So, we have needless disability, and no surety that the ON/MS symptomology is reversible.While on the second STD, symptomology worsened. An MRI showed significant brain atrophy. So a third STD request was submitted, and approved thru November 25, 1998.
Again, there was no improvement, so a 4th STD request was submitted, and approved through week 26, February 15, 1999. Coincidentally, this is also our wedding anniversary.
That's the end of my STD "benefit," so now I'll have to apply for Long Term Disability, with no guarantee of approval. So, I, like many others, am losing my job along with my health, because the corporate bottom-line is more important than paying the medical bills.
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