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East Bay Man Fights HMO & Wins
Posted: January 29, 2003 at 6:11 p.m.
 SAN FRANCISCO (KRON) -- Arguing with your healthcare provider can be a frustrating experience. But imagine when your life is literally on the line due to an illness.
That's the situation Nick Alfano was in. He's battling an aggressive case of cancer and believed only one doctor could possibly save his life. But his insurance company, Pacificare, didn't agree until Contact 4 got involved.
"This is something I have wanted to do for over a year now, because this procedure, if it is successful of course, and there's no guarantees, it could take care of the cancer that is in my leg," he said.
Pacificare did approve the surgery, but only if performed at UCSF, because that hospital is in network and Pacificare felt it had qualified surgeons to do the job. But Alfano wanted the top specialist in the country in Buffalo, New York.
"I found out they don't do this procedure at UCSF very often and Dr. Cain in Buffalo does it weekly with a 99% success rate." And Alfano said the Roswell Park Cancer Institute in Buffalo quoted him $40,000 for the surgery versus $70,000 at UCSF. But that didn't convince Pacificare.
"They were very resistant, they said we have an in-plan provider, and that is where you need to go," he said.
The denials and appeals went on for months. Concerned that his cancer could flare up again Alfano turned to Contact 4.
We immediately got in touch with John Metz of the California Consumer Healthcare Council.
We were able to get through to the medical director who was good enough to stay on the line while we talked about it, and by the end of the conversation, he made a commitment.
A few days later, Pacificare formally approved the surgery in Buffalo. Alfano underwent the procedure last month.
Everything went smoothly and right now he's clear of cancer.
Metz says Alfano's case is a good example of how patients can get past a denial of medical coverage, if they have a legitimate case.
You have a right to know why you are being refused the treatment you want.
Never ever accept a denial that is unsupported by something in writing. If they didn't give it to you in writing there's a good chance that they didn't know what the reason was for denying it.
As for Alfano, he also has a word of advice: "Just don't give up," he says. "If more people fought the company they would be less apt in my opinion to turn down claims so easily."
Other advice: Get copies of your medical records. You might need them, and they are rightfully yours. Keep all correspondence and notes of all conversations.
If you get the runaround, contact the Department of Managed Care at www.hmohelp.ca.gov or the Consumer Healthcare Council at 1-888-CalCouncil.
(Copyright 2003 KRON 4. All Rights Reserved.)
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