How To Fight Back
In Real Life - Andrew
From the publishers of the New England Journal of
Even suffering from cardiac myopathy heart-muscle damage
caused by a viral infection Andrew Zellers-Frederick mustered the stamina to fight
through his health plan's appeal system and win.
Zellers-Frederick, of Warminster, Penn., was in his
energetic mid-30s when his condition was diagnosed in 1992. As executive director of a
historical site he had the detail-orientation and verbal ability to make his case
Even so, it took six months and three rejections
before Keystone Health Plan East was persuaded to approve the $7,000 worth of cardiac
rehabilitation two cardiologists had agreed would prevent or at least delay the need for a
When he was first diagnosed, Zellers-Frederick says,
his doctor ordered him hospitalized for cardiac catherization. But in a dither of
confusion about whether his doctor was covered "they reversed themselves
three times in an hour" Zellers-Frederick says the plan essentially had
him kicked out of the hospital without the procedure. (When asked for a response, a
spokesman for Keystone Health Plan East says he can't comment on an individual case.)
"I wrote a letter of complaint about that, and
an executive responded with a sincere letter of apology and said to call her if we had any
future problems," he says. So when the health plan denied a $7,000 course of therapy
intended to forestall a risky heart transplant costing untold thousands, Zellers-Frederick
tried to contact his new friend in the health plan and found she'd left the company.
With his primary-care physician and two eminent
cardiologists vigorously behind him, Zellers-Frederick appealed the denial of care in
writing. Keystone rejected the appeal. He appealed again in writing. Keystone rejected the
appeal. Zellers-Frederick and his wife went to the next step in the internal procedure, a
hearing in person before Keystone arbiters.
"It was almost like a court, except that one of their own employees was representing
me to Keystone," he recalls. Keystone rejected the appeal. This time
Zellers-Frederick appealed to the state Department of Health, which in Pennsylvania
regulates HMOs. The regulators ordered Keystone to cover the treatment.
Once it was under orders, Keystone "moved
mountains" to get the therapy going, Zellers-Frederick says, and covered follow-up
care with no problem. Tests now show significant improvement in his heart.
"It was hard," Zellers-Frederick says of
his struggle to get the procedure he needed. "You have to document, take names,
record everything and don't be afraid of them."