Hello- In addition to being the worried wife of an SMM patient, I have owned and operated a 'patient advocate' medical claim management service for more than 18 years. I will happily tell you what my experience has taught me. In the years I have been advocating for patients, auditing bills, solving problem claims, and filing appeals, I've seen many ugly things out there with the insurance industry.
First, yes, his plan may have a lifetime max. Many do, in fact, most do. Several questions come to my mind immediately. Is this a plan from an employer? If so, do you know if they're self insured (they don't broadcast that, it may be hard to find out). If so, they may pay claims 'outside the contract'. If that's the case, you'd want to contact his employer, not the insurance company. The insurance company can do nothing. Self insured or not, a plan limit is a plan limit, and nothing is going to change it. But if the company is self insured (definition: they pay all their employees claims themselves rather than paying premiums for traditional insurance. They hire a third party administrator, often a large company like BC/BS, Cigna, or United Healthcare, which is why you may not realized it's self insured)., then they can make exceptions as they like, and instruct the third party admin (TPA) to waive the cap and pay his claims. Almost all large employers are self-insured, but it's a well kept secret.
Whether or not it's self insured, another question is this: Has someone audited his bills to see if they really add up the cap, or are you just taking the insurance company's word for that? It can be hard to audit, if the charges go back very far, but may well be worth it. Only charges they 'allow' are applied toward this cap. Do you know what the cap is? You'd have to know this audit it.
In some cases, a congressman may be willing to go to bat for you, but he has traditional insurance, and the cap was clearly listed when he bought the policy, or was in his employer's benefit plan booklet, there's just no fighting. It's black and white, period. His employer chose to only pay for x benefits, and x benefits is what they're going to get. Equate it to going to a restaraunt,, paying for a cheeseburger, and they saying that you ate it all, still feel hungry, and feel you should be given a lobster dinner without any further payment. Not gonna happen.
I'd talk to the Department of Public Welfare (even if you think he doesn't qualify, call anyway, you'd be surprised), to see if he qualified for Medicaid based on his condition and the loss of his benefits due to exhaustion.
Is he disabled? If he is on SS Disability, then he will eventually get Medicare (after 2 years, I believe), which has no cap. If he's not yet been declared disabled, you may want to work toward that. Medicaid may fill in for now, but overall you have less choice of docs and treatment than you would with Medicare.
So now that I've written the book.....(sorry, I do this all day, so I'm very well versed in giving advice...), please let me know if there is anything else I can answer. I'm sure others here on this board may also benefit from some 'benefit' advice!
1worriedwife
On 3/6/2008
mmsurvivor wrote:
Unfortunately they can, and do. o. It is a sin to deny really ill people the peace of mind that insurance takes. Because of his stage 3 most insurance companies will not touch him but where I am it is not an option to refuse insurance. Why not try and talk to the insurance company and see what they say. Is there a senator or someone with some power to help. I think you can go on disability and medical in this situation, if he has no funds...look into that he is definitely eligible for disability. I will also write you a private email with some information. mms.
On 3/6/2008 luckykl wrote:
I recently posted a message about my uncle who has stage 3 MM. He finished his last treatment of Revlimid about 2 weeks ago and has been sick as a dog since. We just got the terrible news that he has reached what is called a life cap and his insurance is terminating his coverage effective March 1, 2008. Has anyone run into this problem?? I know the various treatment for MM are pricey, but how can an insurance company cut you off when your life is depending on the treatments you are getting?? Any advice? As if the diagnosis has not been enough on the family :(