I had a stroke / then a PFO Closure / Then my evil Insurance Copamny denied payment on the $100,000

My name is Charles Piper. I have no ulterior motives, no massive legal team, no nothing. I am simply a computer programmer for the state of Texas and have been for 25 years. I have a family of 2 daughters (5/10 yrs) and a female Corgi named Marley after the musical genius. I live in a big metro area of about 1 million people. There are a lot of brilliant doctors here who know what the best medical care should be, particularly the very specialists who devised my game plan.

On June 2, 2010 at the age of 49 I had an ischemic stroke that hit my brain in 3 places. By miracle I am OK, more or less. I have been in great condition all my life and have always been within 5 pounds of my high school weight of 155. I have always worked out 7 days a week, grew up playing competitive tennis. Still work out daily. I was in the city's biggest hospital for 5 days. They did every test I think ever invented, and after the 2nd day, a heart bubble exam. about 30 minutes after that test the heart specialist came in and, I quote, said "Do you know who Ted Bruschi is? You had exactly what he had.". No exact stroke cause with no stroke risk factors of any kind to battle.

The next 6 weeks I spent going over what to do with my primary care physician, 3 heart specialists, and 3 neurologists, not to mention a lot of other doctor opinions. After multiple referrals letters from the Insurance company, preliminary tests, several specialist visits, I got the heart operation at the city's biggest hospital on July 7, 2010 to close my PFO opening. The doctors presented that as a Michael Jordan-esque slam dunk.

Then the dreaded hell arrived a month ago. The evil component to all this (aside from the actual friggin condition), my Insurance provider for me and over 200,000 other state employees, has denied paying the $100,000 claim by labeling it experimental. A room full of "suits & ties" are telling the medical profession here they were wrong. THAT ITSELF IS BIZARRE! I have one shot of an appeal with the state agency in charge, so I win there or else it really gets weird for me.

I am "shotgunning" to anyone & everyone to see if anybody out there cares and has any tips, advice, internet links, or insights that would help me present my case better. That happens probably around January 2011. I need to focus on why this is not experimental.

I don't have a spare $100,000 laying around. I have two daughters who will eventually need braces and college, not being victimized by Insurance robbery. Any help delivered by anyone in any fashion would be greatly appreciated.

Later and thanks

<Edit>  I have removed your email from the open forum and strongly suggest that you put it is your profile to protect you from being spammed.

Thank you and I will respond to your post today. 

Kitt

Post Edited By Moderator (stkitt) : 11/9/2010 7:43:16 AM (GMT-7)

Hi Carlos, I am sorry, and shocked, that this can happen. Sadly you are not alone in this battle with insurance companies. (Being in the UK means I wont go through this. The NHS does have some good points!)

I found this artical, Clinical outcomes of patent foramen ovale closure for paradoxical emboli without echocardiographic guidance.

http://ukpmc.ac.uk/abstract/MED/15274165

This just takes you to the abstract but it may be worth subscibing to if you are to collect enough data to prove your case. If you click on the citations tab it gives you links to many other studies. This is a 2004 paper and I am sure there are more recent ones. Good luck - you do this for all of us.
x stillsmiling

Charlie,

Sorry for the edit however to keep you compliant with the rules of the forum I removed your links.

Thank you in advance for your understanding.

Kitt

Hey x stillsmiling

Thanks a ton. That's the type of stuff that could help. I have stumbled upon a few like this and none seem free. I would pay for some if I knew the outcome. I mean, I don't want to spend something like $25.00 only to find out the paper is useless. I found a few that even wanted $500. Yeah, right.

Anyhow, I will be hitting up your link ASAP.

The internet, sites, forums, organizations, etc., are great but they do tend to bypass one of the most stressful components of this health puzzle- when you think you have insurance but then come to find out you don't. Where to start the fight?

In closing, thanks. How about a punchline to end on: the bill they denied has 6 transactions spread out over July 7 and July 8. These jerk offs are paying for 4 of the 6 but not the 2 expensive ones. Not only are they arrogant, they are sadistic.

Later, Carlos.

It's generally accepted that prior to surgeons and hospitals undertaking such procedures that they receive a pre-authorization from the insurance company.  It seems that your team failed to do this, and it's to them I would put this question about payment.  Someone dropped the ball.  I've had prostate cancer surgery and heart stents inserted within the past two years - both procedures at a great expense - and neither was done without the advance approval of the insurance company ... which is the requirement of my policy.  Best wishes for a successful outcome to your situation.