THE TOUGH CUSTOMER – Mon Dieu!: Accident causes French disconnection

I happened to see Michael Moore's new film, Sicko, last week. The film paints a frightening picture of a U.S. healthcare system that seems more intent on making a profit than promoting good health.

Coincidentally, the next day I heard from a very frustrated Eddie Mikell of Zion Crossroads about his recent vacation with his fiancée, Judy Adams. Their story is of a piece with the stories in Sicko.

Along with another couple, Mikell and Adams rented a French country home for a week in early June. While they were driving to the house from the airport on June 5, however, a transport truck clipped their car, sending it down an embankment. 

Mikell escaped with scratches and bruises; the other three were rushed to a hospital. Adams and Tom Ganaway each fractured several vertebrae, and Pat Ganaway suffered several broken ribs.

Mikell, literally the last man standing, got busy the next day notifying everyone's insurance company, a task complicated by the time difference and fact that, as Steve Martin once famously observed, "Those French have a different word for everything."

After a number of calls over the next two days, Mikell finally connected with Chris Patrino, who handles complex cases for Southern Health, which administers the health insurance plans at UVA, where Adams works.

Mikell then set about trying to figure out how to get everyone home. Mikell says the French hospital told him to arrange transport that would allow the two with broken backs to lie flat.

Over the course of the next few days, both Mikell and Adams spoke several times with Patrino trying to make arrangements, but according to Adams, Patrino "made no suggestions and offered no guidance."

By Friday, June 8, Mikell decided to take matters into his own hands. He paid Adams' hospital bill (about $3,200), arranged for ambulance transport to Charles de Gaulle Airport (about $700), coordinated transport with Air France, which required first class travel for flat-folding seats (about $12,000), and arranged for an ambulance from Dulles airport back to their home in Zion Crossroads (about $700). Total: about $16,600.

Most of these claims are pending, but Mikell says he has the impression that Southern Health will deny coverage. For example, Patrino allegedly told Adams, while she was still in the hospital, that Southern Health would likely deny the ambulance from Dulles because there was not enough information to establish its medical necessity.  So, upon landing, Mikell took Adams directly to nearby Reston Hospital for an examination. There, Dr. Rodney Biglow wrote, "Recommended patient have ground transport to help prevent excess pressure on back. Go by stretcher." 

They faxed this note to Patrino who, according to Mikell and Adams, claimed he could not read the doctor's handwriting. 

Furthermore, as far as she knows, Adams' medical records have not yet been translated, although Patrino allegedly has suggested to her that they contain inadequate information to establish the medical necessity of her hospital and transportation bills.

A spokesperson for Southern Health says she cannot discuss Adams' case due to privacy laws. In a prepared statement, Cosby Davis III, company president and CEO, says that under UVA's program, members are covered for emergency care any time. "Preauthorization is not required for a medical emergency," Davis says. "The UVA Health Plan has preauthorization requirements for certain services in order to determine medical necessity."

Meanwhile, UVA spokesperson Carol Wood says privacy laws prevent her from discussing the case. She notes, however, that UVA's insurance plan is top-notch, and that it includes an appeals process for denied claims, something Davis also noted.

Privacy laws certainly make it hard for Southern Health to discuss specific cases, and it's well known that insurance coverage is rife with technicalities. But never mind her ruined vacation; Adams' broken back is not a technicality.

The couple makes the case that they tried to coordinate with Southern Health under difficult circumstances in a country where they didn't even speak the language.

Isn't the whole idea of insurance that it will be there when people need help? If Adams' case doesn't qualify as such a situation, what does?