THE TOUGH CUSTOMER- Claims confusion: She finds denial a flat-out hassle

When we left Judy Adams several weeks ago ["Mon Dieu! Accident causes French disconnection," June 28], she was flat on her back recovering from fractured vertebrae she suffered in a car accident in France on June 5.

Along with her fiancé she was waiting for Southern Health, the administrator of UVA's self-funded health plan, to decide on her insurance coverage. Based on some ominous rumblings from the company, she was not optimistic.

Checking in with her last week, we found that Adams' case has become, in the words of Alice in Wonderland, "curiouser and curiouser."

As Adams feared, Southern Health denied the bulk of her claims– $13,400 for first-class plane tickets and ambulances, both of which Adams says were necessary for her to travel home by stretcher after the accident.

Southern Health, citing Adams' French hospital records, as well as a June 11 follow-up examination at UVA's emergency room, concluded that neither her flight home nor her ambulance transport was "medically necessary." 

Adams, however, says that when she called Southern Health to obtain her translated French medical records, which she needed for her appeal, a customer service representative could not locate them– because apparently no claim had ever been filed on Adams' behalf.

Adams was confused. "How can they send denial letters for claims they don't have?" she asks.

Southern Health spokesperson Mary Sandridge, claiming she was unable to discuss Adams' case due to privacy laws, said Southern Health had provided translated hospital records to Adams. Acknowledging Adams' confusion, she added that Southern Health would "reach out to her directly to offer clarity on her next steps in the appeals process."

Adams also says that the physician who treated her at UVA, Dr. Vincent Arlet, has since told her that, contrary to Southern Health's finding, he agreed that Adams needed to remain flat on her back when she traveled; Adams says Arlet told her she would have required at least two to three weeks of recovery before being able to travel sitting up in cars and airplane seats.

Also, Southern Health's position is contrary to the June 9 examination of Adams at Reston Hospital, immediately after she landed at Dulles, when Dr. Rodney Biglow recommended– in writing– that Adams have "ground transport to help prevent excess pressure placed on back." He added: "Go by stretcher."

Further, Adams broke her back, and remaining flat for a transatlantic journey seems reasonable to her. But even allowing that common sense and medical reality can sometimes conflict and that there was a lack of documentation from French physicians, do the unique circumstances of Adams' case warrant something more– a phone call to France, perhaps– in addition to reviewing written records?

Given Adams' clear understanding of the conditions of her discharge– that she had to travel flat on her back– it's probably not unreasonable to consider that a French doctor in a universal care system might not keep as extensive written records as might an American doctor versed familiar with the minutiae of our insurance system.

Sandridge couldn't comment on that aspect of the process, and Southern Health's medical director, who could, wasn't available.

Adams hopes the appeals process will resolve these issues, but in the meantime, the situation is taking an additional toll.

"I'm very frustrated," she says. "It's bad enough dealing with being in a brace for two months, but when the days are filled with paperwork [and] phone calls, [it makes] it very hard to rest and recuperate. Not to mention the stress!"