THEIR RULES, OUR PAIN

Real stories of people trampled by the insurance companies

"My story is my mother's story. She got fast-talked into joining a private Medicare HMO instead of keeping the public Medicare plan she always had. ‘Look at all the extra benefits you get as compared with Medicare,’ she and other seniors were told by a slick HMO salesperson at a neighborhood meeting. She lived independently in her own home in good health until one night she slipped and broke her hip and was hospitalized for surgery.

The story after that was the same for almost a year: the HMO was there at every juncture fighting to deny or delay the care she needed. They kicked her out of the hospital before she was ready, then tried to cut short her rehab in the nursing home, bringing in their own doctors to pressure the nursing home staff into saying she was ready for discharge when she couldn't yet walk, and had infections contracted in the low-bid facilities they had placed her in. ‘The HMO booklet says she is covered for 100 days in the nursing home,’ I pointed out. ‘That's only if she's making progress,’ the HMO countered, ‘and our doctors say she isn't making progress.’ But she could not progress in her physical therapy until the infections had subsided, and the HMO refused to acknowledge that or allow any more time.

I filed an external appeal with Medicare and won an extra 60 days in the nursing home for her, but the HMO refused to give her physical therapy so she was confined to her bed and contracted bed sores, bladder infections, and pneumonia. At the end of the 60 days, the HMO was there again insisting she was ready to be discharged, when she could not get out of bed and required a nasal feeding tube! Another appeal to Medicare forced them to keep her in the nursing home until the tube could come out.

“Repeated trips to the hospital emergency room due to nursing home contracted infections forced the HMO to grant my mother additional 21-day stays in the nursing home. After nearly one year of unsuccessfully fighting this broken, inhumane system to get the care she needed, I lost my mother in January of 2007. After being denied necessary care and treatment at every turn, she died in the nursing home from pneumonia she contracted there. I blame the HMO—had she received the care she needed early on, she would have gotten back on her feet after her hip surgery and gone home. Ironically, she and the profit-conscious HMO would also have been spared the grief and expense of repeated trips to the hospital emergency room.

“Her story is far from unique. I saw many others in the hospitals and nursing homes being victimized by these Medicare HMOs, many with no relative or friend to advocate for them. The bottom line is that the for-profit insurance companies make money not by providing health care, but by denying it, and their agents are on the ground employ every trick in the book to see that care is denied, and to find loopholes in their written insurance policies. The health care professionals who haven't yet become jaded and succumbed to the system must spend an inordinate amount of their time and energy fighting to justify the tests and treatments they have prescribed. Most of them I encountered had already been worn down. They would say, ‘She really ought to have a X, but the insurance will never pay for it, so all we can do is X.’”

Tell Us Your Story!

Learn about other ways insurance companies routinely deny coverage in this week’s Foul Play.

Read other stories in the "Their Rules, Our Pain" archive.