My Best Friend gave me permission and even encouraged me to post this as a diary. This is a letter she sent to her Representative and Senators. ( by the way, her US Representative is a Republican, both of her Senators are Democrats who will vote for this bill and have voted for this bill, not so with the Republican House member, of course)
This is a case of someone whose husband is an experienced and well educated engineer who works for a company where the employer has not been able to afford to carry the quality insurance he once was able to offer. She is an award winning journalist and photographer. But the jobs available in her area limit her income potential considerably particularly in this economy with the job situation as it is. Newspapers are laying off writers, photographer, editors and shutting down some newspapers entirely.
She and her husband both work but her part time job does not offer any health benefits so they and their child have no choice but to be covered under the husband's plan.
I did not want to list names so where you see a __ is in place of a specific name of a person
Dear Rep. ___________
Imagine being sentenced to two weeks in enough pain that you could not sit comfortably at the dinner table.
I’m not talking about being sentenced for a crime – at least not one that I have committed. I am talking about being forced to endure pain needlessly because of my health insurance company’s greed.
On Sunday, Jan. 24, I experienced what I thought was muscle pain due to tightness or a muscle spasm. The following day it was worse. I took twice the recommended dosage of over-the-counter pain relievers just so I could function at my part-time job at a newspaper. By Tuesday, Jan. 26, I could not stand it and made an appointment with my family doctor, who said it appears I had either a pinched disc or perhaps a herniated disc on my cervical spine (that’s the neck area), probably between discs 6 and 7. He prescribed an MRI, which I scheduled for Fri., Jan. 29 at 2 p.m.
My insurance company, Aetna, requires a referral for any such procedure. I called my doctor’s office within 30 minutes of their opening on the morning of Wed., Jan. 27, to get the referral. They sent it through to Aetna that same morning, according to ___ who works in my doctor’s office.
Friday, I arrived for my appointment for the MRI only to be told there was a problem with my insurance. My MRI was not denied – but as of 1:30 p.m. – 30 minutes before my scheduled appointment – Aetna had not yet made up its mind whether it would authorize and cover the procedure.
A supervisor at the MRI place made several phone calls on my behalf, while I waited, wondering if I would get authorization for the procedure in time for my 2 p.m. appointment. Aetna told the MRI office supervisor that they had "until 8 p.m." to decide whether to authorize the procedure. I have no idea who decided they had until 8 p.m. but if common courtesy were their guideline, they would have had a decision before my appointment time. To make a long story somewhat shorter, I went home that afternoon without an MRI and proceeded to make phone calls to Aetna, who insisted they required 24 hours to review a request like mine. Aetna representative _______ insisted they did not receive the request until Thursday morning despite the fact that I requested the referral from my doctor on Wednesday and, according to my doctor’s office, it was processed immediately that morning. In other words, Aetna had more than 48 hours prior to the appointment to review the request.
They did not officially deny the request until Monday, Feb. 1. They told me the reason was that I had spent eight weeks under a doctor’s care trying alternative treatments such as physical therapy. What is most ridiculous about their so-called reason is I did, in fact, go to physical therapy! They paid the bill – or part of it anyway, as my copay was $440 – but not until after making various excuses in an attempt to avoid paying. They knew I had gone to physical therapy specifically for neck and shoulder pain and yet, they claimed I didn’t in an attempt to avoid paying for a portion of an MRI. I say "a portion" because my copay for an MRI is $100. Believe me, I won’t fork out $100 out of pocket for something that’s unnecessary.
I received notice of the denial at 8:30 a.m. Mon., Feb. 1, when I received a phone call at home from Med Solutions, a firm which contracts with Aetna to review claims. They told me they would fax the denial to my doctor’s office and the doctor could appeal if he wished. Interestingly, the doctor did not receive the denial for another two hours.
Meanwhile I was taking Darvocet, a mid-level prescription pain reliever. My job as a writer/editor requires extensive use of the computer, which is extremely difficult because the pain and numbness extends from the spinal column all the way down my right side and all the way down my right arm. To make matters worse, I am right handed.
However, I work part-time which means I don’t have any sick or vacation time. I cannot afford to take unpaid time off due in no small part to my medical bills. In addition to the $440 copay for physical therapy, $20 primary doctor visit copay, $40 specialist visit copay and $80 copays for pain prescriptions, I will owe another $100 for an MRI – should Aetna decide to authorize it. That sum – which adds up to $680 – does not include any additional copays which will be required for the procedures needed to actually treat the condition. Nor does it take into consideration routine out-of-pocket medical costs including but not limited to the $250 a month I pay out of pocket for prescriptions and supplies to treat my diabetes and other long-term chronic but manageable (with treatment) conditions. And I pay that much out of pocket despite having prescription "coverage."
So I doped up and went to work. I had no choice.
That Monday – Feb. 1 – my doctor decided the best way to get me the treatment and testing I needed was to send me to a specialist, who prescribed Vicodin for pain. Although this drug is more potent than Darvocet, it does not take away the pain entirely. It simply dulls it to the point where I can function. If I want no pain, I would have to take something like Oxycodone, which would probably leave me unable to drive safely or function properly at work.
It comes as no surprise that the specialist said I have either a pinched nerve or a herniated disc and I need – get this – an MRI! In all probability, the treatment will be an epidural injection, which cannot be given until after an MRI is done.
I currently have an appointment for an MRI for Thurs., Feb. 11, assuming Aetna does not try to fight the specialist over his diagnosis. My doctor seems to think Aetna will be less prone to fight the specialist, but who knows. If I do get the MRI Feb. 11, it means my pain was drawn out needlessly for two weeks. If I don’t get the MRI, it will mean my pain will continue indefinitely.
This is not the first time Aetna has fought me or tried to block my access to basic health care. I suffer from allergies, which leads to a chronic cough which in turn aggravates the neck and muscle pain described above. My doctor prescribed Allegra. Aetna fought me, claiming I need to try over-the-counter alternatives first. When I said I did, they finally approved the prescription, though that approval means little. The full retail cost of the drug is $88 a month. I pay $78. Aetna pays a whole $10. I just learned I can get the prescription cheaper using a county sponsored discount program and not going through Aetna at all. The same is true for blood pressure medication I take. In these cases, it is cheaper to go as an uninsured party through this discount program than to use the insurance for which I pay $2600 a year out of pocket. (This figure does not count the additional premium paid by my husband’s employer). And I am sure that is just how Aetna likes it.
Incidentally, for the calendar year 2009, I paid $8600 out of pocket for health care. And although I have diabetes, I do not have any serious health conditions such as cancer or MS. I can only hope I never contract a serious illness because I am sure that would leave me bankrupt, assuming I don’t end up dead first.
I am sure you are aware that a health care reform debate is currently raging in this country. I urge you to work towards real reform that reins in the powerful insurance companies because what is happening to me and countless others across this country is absolutely criminal. Companies such as Aetna should not be allowed to put their profits above the health of their customers – the very people they are being paid to protect. And they are making a profit. A Feb. 7, 2008 press release issued by Aetna itself listed the health insurance company’s profits at $1.8 billion.
I realize the health care debate has caused lines to be drawn between the two major political parties. But this is not a Republican issue or a Democratic issue. It’s an issue of fairness and decency for the everyday American people – and by that I mean those of us not covered by the excellent health care insurance plan members of Congress enjoy, and those of us not benefitting from massive health insurance company profits. Americans are supposed to have the right to life, liberty and the pursuit of happiness. But we cannot live when we cannot afford basic health care. And we certainly cannot pursue happiness when we are in too much pain to even sit at the dinner table.