JustHealth
Working for Health Care Justice - Now!
Stories from the Real World of Healthcare in America
Have you or someone you care for ever had an insurer delay, diminish or deny a claim because the insurer claimed it:
This happens every day, all across America.
A man goes to a primary care physician. The services are covered by his insurance, but his insurer doesn’t pay. They claim they never received the paperwork. The doctor says he sent it. The patient sends it again two more times. The insurer still says it hasn’t received the paperwork. JustHealth gets involved. The insurer pays. [JustHealth has seen this “we didn’t get the paperwork” – “then we found it once JustHealth got involved” so many times that even James Bond would have suspected it to be “enemy action”]
Have you or someone you care for ever had an insurer deny payment for a needed treatment or service because the insurer claimed it was:
This happens every day, all across America.
A remarkable high functioning professional woman, living for decades with an above the knee amputation, is denied a new hi-tech prosthetic leg because her insurer claims it is “investigational”. “Investigational”!!! The FDA approved it. It has been in common use for more than a decade. It is a standard level of prosthetic care. It is approved by the Veterans’ Administration and regularly given to returning vets who have lost the lower part of one or both legs. It permits amputees to function at a higher level with far less chance of falling. All available and, even, other member companies of the same insurer group say it is not “investigational”. Her insurer continues to deny coverage. Every day that goes by places her at increased risk of falling and injuring herself more, much more. JustHealth gets involved. The insurer pays. She’s doing fine.
This insurer changes its position. Some other insurers continue to deny amputees these legs because they claim the legs are “investigational” / “experimental”. How do these insurance people live with themselves?
Have you or someone you care for ever had an insurer deny coverage for a necessary treatment because the insurer claimed it was:
This happens every day, all across America.
The parents of three, incredibly cute, developmentally disabled little children sought speech therapy for two of them. Their insurer told them it is “not medically necessary”. All of the treating physicians state otherwise … unequivocally. The insurer sends the parents’ appeal to an outside company that earns a substantial portion of its income from this insurer. The outside reviewer agrees that the treatment is “not medically necessary”. (Quite a surprise?) The denial is further bolstered by the insurer’s Medical Director … who is Board Certified in Obstetrics and Gynecology. (This man is also known to make determinations of medical necessity in cases involving cancer and a host of other diseases about which he is not qualified to speak.) But these parents are fighting for their children’s futures. They keep pushing … and get nowhere. JustHealth gets involved. The first child gets the speech therapy. The insurer denies coverage for the second child. JustHealth gets involved. The second child gets the speech therapy.
Have you or someone you care for ever been denied coverage for a necessary treatment for which:
This happens every day, all across America.
Their daughter had a severe, life-threatening eating disorder. Insurer has no local facility to provide required treatment. Insurer refuses to pay for treatment. Father is a senior lawyer in a major insurance defense firm. No matter. Insurer refuses to pay. Family is forced to pay tens of thousands of dollars out of their own pocket to get essential services. The father contacts us. JustHealth get involved. The insurer pays the entire amount. [The daughter is doing fine, now.]
A man in California had a major problem with his leg. His insurer had no qualified provider to treat the man. If he didn’t get the needed treatment, he was likely to lose his leg … maybe die much sooner. The place that offered the needed treatment was on the East Coast. The insurer refused to pay. He could not afford it without the insurance he paid for. JustHealth gets involved. The insurer agreed to pay. The man got the treatment he needed. Last JustHealth heard he was doing fine.
Have you or someone you care for ever had an insurer:
This happens every day, all across America.
A woman’s deep vein thrombosis is misdiagnosed, causing a pulmonary embolism, leading to the need for a hysterectomy and to other subsequent periodic emergencies. The insurer cancels her coverage, even though it had no right to do so. JustHealth gets involved. Her coverage is reinstated. They want to impose an onerous condition on the reinstatement. JustHealth gets involved. They give up on the onerous condition.
Have you or someone you care for ever had an insurer deny coverage for a severe, potentially deadly, eating disorder in a teenage child because the insurer claims the eating disorder is:
This happens every day, all across America.
A teenage girl (most with this disorder are teenage girls) has a severe, potentially life threatening eating disorder. To save her life, she needs to be treated in a specialized in-patient facility thousands of miles from home. The insurer refuses to pay because it claims that the eating disorder is “not biologically based”. “Not biologically based”??? The depravity of the insurer’s position beggars the imagination. And this position affects hundreds and thousands of young women and their families.
JustHealth gets involved. JustHealth contacts the insurance company’s CEO on a Sunday evening at his home. The next day the CEO, the head of his PR department and his General Counsel take a call from JustHealth and the child’s mom. The CEO refuses to budge. The family refuses to let their daughter die. After several years and numerous lawsuits, the insurer agrees to pay. How many children died in the interim?
Have you or someone you care for ever had an insurer refuse to pay on a disability income insurance claim because the insurer said:
This happens every day, all across America.
A man, the long-time manager of a successful auto dealership, becomes disabled. He can’t work. Some days he can barely move. He has disability insurance. The insurer refuses to pay the promised benefits. (At the same time, his wife, the mother of his two children, is diagnosed with breast cancer and undergoes a double mastectomy.) The family seeks help from the Department of Insurance. The Department tells them that their regulations do not apply to disability insurers. JustHealth gets involved. The Department is wrong. JustHealth get the Department to file an action against the company. JustHealth’s friends in the media bring the story to the attention of the public. The company pays something to the family (albeit, far less than it owes, which they are forced to accept because of their dire circumstances – a common occurrence.) The Department fines the company $150,000 or so – far less than its misconduct warranted (another all too common occurrence.)
Have you or someone you care for ever had an insurer require you to use an In-Network Provider, even when the
This happens every day, all across America.
A man and a woman have essential tremor disease and need a highly specialized surgery to regain their functioning. The same insurer directed them to have deep brain stimulator implants put in by one of its surgeons. The woman got nervous when the surgeon lied to her about something. JustHealth gets involved. JustHealth discovered the surgeon was wholly unqualified to do the work. The insurer was, essentially, using these folks as guinea pigs to train this surgeon. These patients got their surgeries done by competent surgeons outside the insurer’s network. The insurer paid.
Numerous men had prostate cancer. Their insurer’s providers refused to disclose information on their outcomes. The only information obtainable showed that they told the men to expect that 90% of them would be impotent and/or incontinent after the surgery. Top notch facilities around the country offer success rates of 65-80% re: potency and 90% re: continence after the operation. JustHealth gets involved. The insurer agreed to pay to have some of them treated by the top notch surgeons. Nevertheless, it appears that this insurer (the same one that sends people with essential tremor disease to an unqualified surgeon) continues its prior conduct.
Have you or someone you care for ever complained to a Regulator about being treated wrongfully by an insurer and had the
This happens every day, all across America.
A man, the long-time manager of a successful auto dealership, becomes disabled. He can’t work. Some days he can barely move. He has disability insurance. The insurer refuses to pay the promised benefits. (At the same time, his wife, the mother of his two children, is diagnosed with breast cancer and undergoes a double mastectomy.) The family seeks help from the Department of Insurance. The Department tells them that their regulations do not apply to disability insurers. JustHealth gets involved. The Department is wrong. JustHealth get the Department to file an action against the company. JustHealth’s friends in the media bring the story to the attention of the public. The company pays something to the family (albeit, far less than it owes, which they are forced to accept because of their dire circumstances – a common occurrence.) The Department fines the company $150,000 or so – far less than its misconduct warranted (another all too common occurrence.)
When violations of the law are brought to regulators for them to fully and faithfully enforce the laws that currently exist to protect consumers, in the vast majority of cases they do nothing. In those few in which they do anything, the worst result is no more than a blip on the perpetrators’ bottom line. These crimes currently pay – big time!
Doctors, Hospitals & Nursing Homes Issues
Have you or someone you care for ever received a bill from a hospital that seemed:
This happens every day, all across America.
VC, a woman with four children needs to go to a hospital. She is insured. The hospital is not a “Preferred Provider”. She tries to find out what it will cost before she goes in and while she is there. From everything she is told, she believes the most she will owe is her co-payment and deductible - $2,000.
A few weeks after her 4-day hospital stay, she receives a bill for $75,000. The hospital tells her that this is the “usual and customary charge”, i.e. what the hospital calls its Chargemaster Rate, for the services. Her insurer pays $18,000. The insurer tells her that this is the “usual and customary charge” for the services. She tries for months to resolve.
Facing the potential of bankruptcy and life on the street with her children, she contacts JustHealth.
JustHealth makes one phone call to the hospital. About 30 minutes later, the hospital calls the patient and says that they have come to agreement with the insurer. The hospital reduced its price to $47,000 and the insurer agreed to pay it. Both the hospital and the insurer now say that $47,000 that this is the “usual and customary charge” for the services. Her debt is gone and VC and her children can go on with their lives.
Have you or someone you care for ever had a doctor or hospital:
This happens every day, all across America.
A man schedules a procedure at a local Medical Center. He wants to be certain he knows, in advance, how much it will cost him. This seems like reasonable, prudent and responsible thing to do … particularly since more than 50% of all bankruptcies in the U. S. involve medical bills. He is told that his entire cost will be $X. He questions the hospital’s representative, again, to be double sure. Again he was reassured that this will be my only "out of pocket" portion of the bill. All other costs will be covered by his insurer. The hospital’s rep tells him that the hospital always checks with the insurance provider, prior to a procedure. He agrees to go ahead.
Six months later, he receives a bill from the hospital for an additional 2 ½ times what he already paid. He contacts the hospital several times. Sorry, they say. It’s what you owe. It doesn’t matter what we told you. JustHealth gets involved. The bill is eliminated – and the hospital promises to review and correct its procedures. (Such promises are often not kept.)
Have you or someone you care for ever been:
This happens every day, all across America.
A man’s wife goes to an ER, apparently suffering from dehydration. A similar thing had happened many years before. It had taken a short time to remedy and cost them less than $1,000. Before they know what is going on, she has been told that she has a brain tumor and a variety of other terrible diseases (none of which turned out to be true), been subjected to numerous tests, spent about 60 hours in the hospital and was given a bill of approximately $50,000. They are faced with threats of being sent to collections by the hospital and/or various doctors’ groups. To pay the bills would likely bankrupt them. But, that’s not really the point. The bills are wildly inflated, even if everything that was done had been necessary. (This was by no means certain.) If they are sent to collections, that alone can cause them great harm. They are caught between a rock and a hard place.
JustHealth gets involved. The bills are reduced to less than $5,000, to be paid over 3 years. With luck, they and their permanently disabled daughter will be able to survive.
Have you or someone you care for ever had a doctor or hospital:
This happens every day, all across America.
A family moves. They need their child’s medical records from former doctor in order to get special needs services from local school district. Doctor says, don’t know where they are. Sorry. The family tries for months to get him to find them or provide them with the information they need. He refuses. JustHealth gets involved. JustHealth gets the family what they need.
Have you or someone you care for ever had a doctor or medical group tell you / them that:
This happens every day, all across America.
A woman has breast cancer. Her Medical Group acting like her Insurer “doing the dance” delays and denies needed care. JustHealth gets involved. She got the needed surgery. A year or two later, she calls again. The Medical Group/Insurer “doing the dance” again, delaying and denying needed care for required breast reconstruction. She feels as though she is in a metal vise all the time. JustHealth got involved. She got the needed work done.
Have you or someone you care for ever complained to a Regulator about being treated wrongfully by a Doctor, Hospital, Nursing Home, etc. and had the
Almost every day, governmental regulators refer people to JustHealth who contact them with complaints about hospitals, doctors, nursing homes and other healthcare providers, because they will not enforce the regulations that they have the authority to enforce.
When violations of the law are brought to regulators for them to fully and faithfully enforce the laws that currently exist to protect consumers, in the vast majority of cases they do nothing. In those few in which they do anything, the worst result is no more than a blip on the perpetrators’ bottom line. These crimes currently pay – big time!