Aetna Denied Brain Surgery to a 19-year-old

[mtf80123]

Story

Caitlin needs immediate surgery for her condition, and she was hours away from getting it.

The problem? Her insurance company, Aetna. They approved the operation 15 minutes too late. Caitlin lost the operating room to another patient and had to be rescheduled.

Then, the company came back with an even bigger shocker. They told her they would not cover her brain surgery at all, that her benefits ran out.

The family would now have to foot the bill at a staggering $113,000. Tampa General Hospital was requiring $55,000 down, and the rest after the operation.

[iamjoy]

1. Very Short On Facts

Is it really Aetna or was Caitlin's coverage through an employer based health plan? If it was through an employer plan was it a fully insured plan (such as an HMO) or a self-insured plan (in general, an PPO).

If it was an employer self insured plan, Aetna adjudicates claims only. In any case, what types of claims or coverage is valid is based largely on the employer's direction and the terms of the contract.

So, Aetna could be the bearer of bad news and the real "bad guys" are the employer.

Or, maybe this poor young woman genuinely did not meet clearly displayed plan rules.

In any case, it definitely points to big problems with our health care/insurance system.

[Kittycat]

2. Some states offer retroactive coverage to pick the child up on the state plan.

In IL, you can get 3mo retroactive coverage depending on if you currently have insurance, or your income. The plan here, I believe, would cost the family a max of $500/mo & $750 out of pocket cap. That's if you make more than $150K/year with 2 dependents.

Our son has special needs, and there is alot left uncovered by insurance between the co-insurance, out of pocket, copays and things not generally covered under the plan. Our income level kicks us out of all the regular special needs plans - so I'm in the process of applying for the states kid care program. We would pay a monthly premium (in addition to what we pay for our regular insurance), and the state's program would act as a secondary insurance, picking up where our regular plan fails. With this, we'll finally be able to put our son in developmental therapy, and getting some learning & therapy devices in-home to help (he has Ataxic Cerebral Palsy and low tone issues).

I never thought we'd have to seek out help, and we've gone 4.5 years of his life without it - but it's not fair to him that he can't get the help he needs, because our insurance won't cover it.

[Xithras]

3. Tragic as it is, the denial is understandable.

A parents health insurance coverage typically covers a child until they complete their education or turn 18, whichever comes last. The woman was 19, had completed her education, was employed as a photographer for Disney, and was actively searching for a job as a massage therapist (which she had completed school for).

The case is horrible, but it's pretty clear that she's not eligible for coverage any longer. The fact that the condition was discovered after she had exceeded the coverage terms makes it even worse for her. I could see an argument if this was a continuing claim from when she WAS a covered minor, but this wasn't discovered until she had reached adulthood and graduated.

The real fundamental problem here isn't that Aetna denied the claim, it's that insurance is generally so unaffordable that an employed 19 year old woman couldn't get coverage on her own and instead had to try to get her mothers policy to pay for it.

[mtf80123]

4. Good argument for...

single payer, not for profit coverage.

[izquierdista]

6. What is understandable

is that the $113,000 would have to come out of Aetna's profits, whereas even if they had to defend themselves in a court case, it would only cost a few hours of in house counsel's time to get the case dismissed with prejudice.

The real fundamental problem here is allowing for profit companies to collect premiums for coverages that they have no intention of paying.

[elehhhhna]

7. she lost her insurance when she aged out...

I had a neighbor (a nurse! you'd think she'd know better!) who kept her daughter on her co's policy until she was 22. Sure, they'll take your payments, they may not notice, and even pay for a few things after the kid's aged out--but when they get a huge claim they're going to check on the insured's policy status.

[Selatius]

5. This is the kind of bullshit west Europeans stopped tolerating at the end of the last World War.

After World War 2, countries like France, Great Britain, and Germany were devastated by war, but they resolved that they would get through it together. With the support of the people and what little of their infrastructure they had left, they developed a plan to bring health care to everyone. The hard times taught them that if they were going to get anywhere, that they would only get there if they worked together.

The level of national coordination was so high during war that few people were not employed in the national effort both in Europe and in America. World War 2 essentially put an end to the Great Depression. If the government and the people could put forward that measure of effort to devastate the enemy's armies, navies, and cities, while dropping unemployment almost to nothing, it could just as easily use that tremendous might for more constructive purposes, and leftists of the era pointed this out to all.

If a country like Great Britain or France could bring forth universal health care coverage despite a devastated infrastructure and millions dead, the US could do it as well. FDR wished that the US would implement universal health care, but he died before the war finally ended, and Truman was unable to muster enough support for such a reform due to Republican resistance.

[Crabby Appleton]

8. The news above is stale - Caitlin had her surgery today

Aetna & Tampa General agreed to cover 100% of the cost

http://www.tampabays10.com/news/local/story.aspx?storyid=85359&catid=8

I would very much like to see universal coverage.

[mtf80123]

10. That's good

I would bet the only reason they finally decided to cover her, was to cover their own asses and nip this story in the bud.

Especially since they are trying to "Amass an Army" of their own.

http://www.democraticunderground.com/discuss/duboard.php?az=view_all&address=103x372221

[Preening Fop]

9. Obviously, Aetna no longer classifies Caitlin, "As a viable Business Opportunity".

A fine example of
the efficiency of the calculating corporation controlled american way
for perfecting the human evolutionary gene pool.