Fight for Your Health: A Story about Crye-Leike’s Jimmy D. Dugger

As appeared in The Tennessean, June 29, 2004.


Written by Sameh Fahmy


Understand insurance policy, be persistent to get what you want


Peristence coupled with the help of his doctors and careful documentation helped Crye-Leike’s Jimmy D. Dugger get his insurance company to pay for his weight-loss surgery


Jimmy D. Dugger thought weight-loss surgery would help protect him from potentially debilitating knee and ankle problems, life-threatening heart problems and diabetes, and four doctors thought so, too.


When his insurance company refused to foot the bill, he didn’t take no for answer. He fought back ? and won.


”If I have letters from four doctors ? four MDs ? telling me that I should have this surgery and that I qualify, then why shouldn’t I have the surgery?” asks Dugger, vice president of Crye-Leike Realtors.


Regardless of whether you’re a candidate for weight-loss surgery, infertility treatments or any other medical treatment, experts say that understanding your insurance policy and knowing how to navigate your insurer’s appeals process can help you get the results you want.


Know your policy


When you sign up for an insurance policy, you’re entering a legal contract with your insurer: You agree to pay them a certain amount and they agree to pay certain health-care costs.


Consumer advocates and insurance companies alike say you can avoid many disputes by simply taking the time to read and understand your insurance policy.


”Most of the time we’re seeing people who didn’t understand their contract,” says Stephani Lassiter, director of consumer insurance services for the state Department of Commerce and Insurance, which helps mediate disputes between insurance companies and their clients.


She says an important thing to look for in your contract are exclusions. These are procedures and services that aren’t covered. If you want cosmetic surgery but your policy lists it as an exclusion, don’t expect the insurance company to pay for it ? no matter how much you complain.


”There are some things that are just black and white,” says Jean Harris, vice president of operations at Blue Cross Blue Shield Tennessee. ”And they can file grievances, but on those black and white things, there’s not a whole lot they can do to have those overturned.”


Most insurance policies also specify certain conditions before they cover a procedure. They may require that you get prior authorization from the insurance company and that the company deem the procedure ”medically necessary.”


Other things to look for are limits of coverage and how your policy defines and covers pre-existing conditions.


Internal reviews


The first thing to do if a claim is denied is to call your insurer’s customer-service or member-service line. Harris says your claim could have been denied because of a simple human error.


Rhonda D. Orin, a Washington, D.C., attorney and author of Making them Pay: How to Get the Most From Health Insurance and Managed Care, says that if you don’t get results from customer service and you get your insurance through your employer, visit your human resources department. Ask them what they can do to help. Your employer negotiates the contract with your insurer, and therefore has more clout than you do.


You’ll likely need to file an internal grievance with the insurance company. The procedures for filing a grievance should be spelled out in your insurance contract. Follow the instructions exactly, and remember that there may be time limits on when you must file appeals.


Orin says you should think like a lawyer when writing your letter. Your task is to persuasively explain why the insurer is obligated to cover your claim under the terms of your policy.


Franke Elliott, vice president of managed care for hospital chain HCA’s Mid America Division, says you should attach all the supporting information you can find. This includes letters from doctors as well as articles in medical journals that show the benefits of a procedure or treatment.


If your first appeal fails, most insurers offer you a chance at a second appeal, where you’ll have a chance to present your case to a committee, either in person or via phone.


Orin says that insurers typically don’t tell you what information they need to reverse a decision, so it’s up to you to do your research, gather your evidence and present your case persuasively.


External reviews


If your internal reviews fail, you still may have the option of an external review by an outside organization.


Most states, including Tennessee, require that HMOs offer an external review for denials based on medical necessity or whether a service is experimental or covered. Other health insurance plans usually offer external reviews as well.


Your plan may have a mandatory arbitration provision. This means that if a dispute is not resolved by internal appeals, you’re limited to arbitration, a process where a third party ? who is not a judge ? resolves a dispute. Arbitration isn’t necessarily bad, Orin says, but it does limit your ability to seek damages in court.


And so does a Supreme Court decision last week.


The Supreme Court ruled that people can’t sue their HMOs for damages related to denials of coverage, since HMOs and policies typically offered by large corporations are governed by a federal law known as the Employees’ Retirement Income Security Act.


You still can sue in federal court, but Orin points out that option allows you to recover only the cost of the treatment and not any punitive damages, which tend to be high-dollar awards.


Orin and Elliott say the decision puts pressure on Congress to pass legislation to protect consumers.


”Now that the Supreme Court has ruled in the favor of the plans, it’s going to create a renewed sense of obligation to get something done at the federal level,” Elliott says. ”But obviously we’re entering another political season and it could become a hot topic.”


Asking the state for help


The state Department of Commerce and Insurance also is available to help consumers resolve disputes with their insurers. State law specifies that if an HMO insures you, you must go through all of the company’s appeals processes before getting the state involved. For all other health insurance plans, you can get assistance from the state at any time during your dispute.


You can download a complaint form from the department’s Web site ( insurance). Don’t forget to include your policy number, which is the number that specifically identifies your policy.


Lassiter says you can expect to get an update on the status of your complaint within two weeks.


”The majority of times we’re able to reach a favorable resolution for the consumer,” Lasiter says. ”And it may be that there is a compromise on both sides, but in most cases we’re able to reach something that everyone can agree on.”


Persistence pays off


Handling insurance disputes can be intimidating and stressful, but consumer advocates say you shouldn’t forgo your rights. You also shouldn’t lose your temper.


”Be persistent, be tenacious, (but) don’t get mad,” Dugger says. ”You can’t get mad. You’ve got to work through it, because if you get mad then you’re going to make them mad on the backside.”


Dugger’s insurance company initially denied his claim because it considered weight-loss surgery experimental. After his appeal with four supporting letters from doctors was denied, he got a lawyer friend to help him out.


And it just so happened that his family practitioner received a memo from his insurance company, Blue Cross Blue Shield, indicating that they were planning to change their policy.


Armed with this information and the help of his lawyer, they found someone at the insurance company who was willing to help.


He had his surgery six weeks ago and already has dropped 30 pounds. Today he’s taking one prescription medicine instead of seven.


”My life is changing by the minute for the better,” he says.


This is where the story should end, but after his surgery Dugger found out that the insurance company rejected the bill from the hospital and his surgeon.


He called his insurance company to straighten the matter out, and as of last week, the company had paid the hospital, but not his surgeon.


”It’s just another hoop that I have to go through post-surgery,” Dugger says. ”I went through enough hoops on the front end. I don’t want to have to do hoops on the backside.”


Orin says many people pay bills that they shouldn’t be paying and don’t get the treatment they have the right to simply because they’re intimidated by their insurance company. Don’t be one of those people.


”It’s very easy (for the insurance company) to deny something and figure that a certain number of people aren’t going to have the strength to take on the denial,” she says.


Keep tabs on it


Consumer advocates say it’s not in your insurer’s interest to make sure that every claim is paid properly, so it’s up to you to closely monitor your insurance company.


Rhonda D. Orin, a Washington, D.C., attorney and author of Making Them Pay: How to Get the Most From Health Insurance and Managed Care, offers the following tips:


? Keep a file of insurance information organized by year.


? Use a notebook to keep track of your family’s medical care for the year. In the notebook, you should keep detailed records of every interaction with your insurance company.


? Before calling your insurer, have a written outline of what you want to say and any supporting evidence you have. Keep a pen on hand so you can take notes.


? When talking to an insurance company representative, make sure they’re entering notes in their system so the company has a record of your call. If you must call back, try to speak with the same person.


? Follow up every call with a letter so that you and the company have documentation that it occurred.


? Make a copy of everything you send to the insurance company.


? Keep everything that the insurance company sends you in your file.


? Keep track of how much of your deductible you’ve paid so you aren’t overcharged.


? Double-check everything the insurance company sends you to make sure that it is not billing both you and your health-care provider.


? Follow up every claim to make sure it’s been paid.


? Samey Fahmy


Sameh Fahmy covers consumer health for The Tennessean. Reach him at or by phone at 259-8072.