THE TOUGH CUSTOMER- Claim of confusion: Broken back highlights healthcare woes

If you want to know why people are dissatisfied with American healthcare– even people with insurance– look no further than the story of a broken back, which I have been following since last summer.

On June 5, Judy Adams broke her back in a car crash while vacationing in France. Adams was hospitalized for several days and fitted with a brace. As she and her fiance, Eddie Mikell (now her husband), returned to the U.S. a week or so later, they incurred about $13,000 of additional travel expense so that Adams, in considerable pain, could lie prone during the journey.

Adams works at UVA, and the University's self-funded insurance plan, administered by Southern Health, declared the special traveling arrangements not medically necessary, and refused to cover the additional expense.

Adams appealed the decision, first to Southern Health and then to UVA Health Plan Ombudsman Joanne Hayden. Both appeals were denied.

Mikell and Adams believed at the time– and I reported– they had the right to appeal one step further to an agency outside the University community, the State Commissioner of Insurance. However, according to a January 20 decision by that office, the Commissioner lacks the legal authority to hear the case because single-employer plans like UVA's are unregulated.

"Our office was created," writes senior Insurance Market Examiner Julie Blauvelt, "to assist individuals covered by Managed Care Health Insurance Plans."

Mikell was shocked by the decision. "I would swear that the UVA spokesperson said we could appeal," he wrote, adding, "I think everyone should know that there is no recourse after UVA turns you down."

How Adams and Mikell formed their inaccurate impression is apparently a mystery. "Both Ms. Hayden and a representative of Southern Health confirmed to me," Blauvelt's letter says, "that you are not eligible for any further review by the State of Virginia, and neither could explain the manner in which you were informed of that possibility."

Hmmmm? Where would Mikell and Adams get such a wild idea?

Perhaps it has something to do with "Your Right To Review the Plan's Determination," a document that Southern Health sent them on June 20, 2007. 

"If you disagree with the Health Plan's final adverse decision," the document states, "and are enrolled in a fully insured plan, you... may appeal to the Virginia Bureau of Insurance."

The phrase "fully insured plan" turns out to be key. Although not defined anywhere in the document, that phrase has dire consequences for the couple's finances. It turns out that single-employer plans are not fully insured plans.

Moreover, nowhere does the document reveal that appeals are available only for Managed Care plans or that Virginia allows self-funded plans like UVA's to have the final word– an omission even more glaring in light of the fact that a portion of the form is specifically designed to spell out differences between UVA's plan and the more general appeal rights section.

Not surprisingly, Mikell and Adams had no idea of the meaning of this small print.

Since I started covering this story, Adams and Mikell have described numerous questionable moves:

1. While Adams was being treated in a French hospital, Mikell contacted Southern Health's Chris Patrino, who handles complex cases, for help in arranging transport back to the U.S., but he got "no suggestions or guidance" before Patrino allegedly stopped returning his phone calls, leaving him to fend for himself.

2. When Adams faxed Patrino a note from Dr. Rodney Biglow at Reston Hospital Center saying Adams should travel by ambulance, Mikell says, Patrino claimed he could not read the doctor's handwriting. The note is legible.

3. In mid-July, after Adams' claims had been denied, she telephoned Southern Health to obtain copies of her translated French hospital records but was told a claim had never been filed and the records could not be located.

4. In denying the appeal, Hayden wrote, "There were no orders in the documentation that stated the patient should lie flat," an assertion seemingly contradicted by Dr. Biglow's recommendation that Adams travel by ambulance.

Neither Blauvelt nor Southern Health returned recent phone calls, and UVA's long-standing position has been that privacy considerations prevent it from commenting on the case.

Given the record outlined above, perhaps that's just as well.

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