Consumer alert: Fighting back when your health insurance does you wrong

- Jim Linn has the battle scars of two knock down drag out fights. The first opponent: A cancer that attacked his spine. The second: A Minnesota insurance company that repeatedly denied coverage for a possible cure. His case is an important lesson for anyone facing a health crisis. It's also a glaring example of a trend uncovered by the Fox 9 Investigators, one that concerns state insurance regulators.

INSURANCE STALEMATE

Jim Linn's medical nightmare started with an excruciating pain in his back.  Doctors found a tumor wrapped around his spine eating away at the bone.  He was at risk of being paralyzed. Neurosurgeon, Greg Sherr removed the tumor and then stabilized Linn's back with metal screws and rods. 

"If you have some luck you get it all and then you treat right away with radiation and you never have to have another operation," said Sherr.

Sherr and three other experts believed Linn's best shot at a cure was proton beam therapy, an expensive treatment to kill off any cancer cells left after surgery.  Unlike traditional radiation, proton beam can zap a tumor without sending a lot of harmful radiation into the surrounding healthy tissue.

"There's no way they could use the regular radiation.” Jim recalled. "It would destroy other organs or it would cause damage to the spinal cord and I wouldn't be able to walk or even worse."

But Linn's insurance company, Blue Cross and Blue Shield of Minnesota said proton beam therapy for his type of cancer wasn't covered. The Linn's argued it was part of their policy.

"I felt they handed Jim a death sentence," said Jim’s wife Gloria.

Multiple doctors contacted the company on Linn's behalf claiming the treatment was a medical necessity, explaining it was the only way to stop the cancer and limit radiation damage to his heart and lungs. 

Months passed and the insurance stalemate continued.

"They would simply pass you around to other departments and put you on hold for long periods of time just to frustrate you." Gloria recalled.

Then, a horrible and familiar pain returned to Jim's back. The cancer grew back. He needed an even riskier operation to remove the new tumor.  He made it through the surgery but now has chronic pain from nerve damage.  Again he pleaded with Blue Cross and Blue Shield to approve the proton beam therapy to kill off any residual cancer.

"I'm thinking they can't deny us now. But they did." Gloria said.

ANOTHER OPTION TO FIGHT BACK

Then the Linns discovered they had another option to fight back, one most people have never have heard of.

"It's very important for consumers to know that they shouldn't just rely on a decision by the insurance company," said Commerce Department Commissioner, Mike Rothman.

In Minnesota, you can take your case to the State's Commerce Department. You pay a $25 fee and the cepartment has an independent firm review the insurance policy and medical records.  It looked at the Linn's case and ordered Blue Cross to pay.

"It was a great feeling of relief and also a tremendous feeling of anger that they put us through a nightmare," said Gloria.

Blue Cross says it can't talk about Jim Linn's case because of legal and privacy constraints.  In a prepared statement it said: "our team of doctors and other medical professionals look at the circumstances of each individual case. Appealing to outside experts for other opinions on the most effective course of care is a right that all of our members have and we abide by those decisions."

TREND OF DENIALS

The Fox 9 Investigators found that compared to other insurance companies, Blue Cross has far more cases being appealed to the state. Now that could just be due to the fact it has more customers,  but Fox 9 found the percentage of its cases that end up being overturned by external reviewers is also significantly higher than other companies.

"I think it is troubling, " said Roth.

Consumers appealed 64 Blue Cross cases to the Commerce Department in 2013. Thirty one percent of them were overturned. There were 108 appeals last year, 31 percent of those were reversed. Of the 90 appeals so far this year, 37 percent have gone in the patient's favor.

"That in itself indicates that there's some decision making process that often times is coming out the wrong way for patients," said Roth.

THE LINN’S DREAM  

Jim Linn eventually did get proton beam therapy at a treatment center in Chicago. For now, it appears the cancer is gone. But he says that additional surgery left him in a world of hurt.  

"It was a lot of pain and suffering that I didn't need to go through," said Jim. He is now suing his insurance company.

"Blue Cross made $10 billion in revenue last year and they're sitting on a billion dollars of retained earnings, earned partly because they've denied medically necessary treatment to individuals like the Linn's," said the Linn's Attorney, Brandon Schwartz.

The company is trying to get the suit tossed out, claiming there's no harm because it eventually did pay for Linn's treatment.

"My dream is to one day have a non-profit organization funded through a grant from Blue Cross and Blue Shield to help people understand this appeal process, so you don't have to stumble through it like I stumbled through it." said Gloria.

The take away here: Be your own advocate. Keep meticulous records of every conversation you have with the insurance company.  And remember  if your coverage is denied you can appeal.  The insurance company is required to pay for the external reviews. The consumer's only cost is the $25 fee, which by the way if you win, you get back as well.

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