Personal Injury Law

$148,000 claim for preauthorized back surgery initially denied

By Hurley, McKenna & Mertz

John Yates reports for the Chicago Tribune, ?Michael Napientek of Clarendon Hills was in excruciating pain and needed back surgery. His wife has worked in the healthcare field for 30 years and thought she knew how to navigate the insurance bureaucracy.? Prior to the operation, his doctor obtained preauthorization for the surgery from his insurance company.

The operation was successful, and within a few weeks Mr. Napientek was feeling much better. However, in April, he and his wife ?began receiving a series of letters from the insurance administrator with chilling news: Claims for the surgery has been denied, leaving them on the hook for the heart-stopping total of $148,000.? When they questioned the denial, they were told that preauthorization does not guarantee that the surgery will be covered. Mrs. Napientek appealed the decision three times, and was rejected every time. Each time, a different excuse was used ranging from accusing her husband of not exhausting ?all conservative means of pain relief? to not providing ?documentation to support the ?appropriateness? of the surgery.?

After many sleepless nights, several months of trying to figure out how to pay the enormous medical bill, and many phone calls to the insurance agency from Mrs. Napientek?s employer who funded the plan as well as from the ?Problem Solver? of the Chicago Tribune to which Mrs. Napientek wrote to report this atrocity, the Napienteks recently received a letter saying the insurance company would pay for the surgery ?based on additional information submitted and the opinion of an independent physician.? The Napienteks had already met their maximum out of pocket expenditure this year, so the insurance company will pay the entire $148,000.

As a Chicago medical malpractice lawyer I find it unacceptable that two working people with health insurance coverage could be driven into financial ruin because of health care costs, especially when the surgery was pre-approved. This story shows how vulnerable all Americans are to the whims and inordinate hassles of the insurance industry, and is yet another example that supports reform.

Full post as published by Chicago Medical Malpractice Lawyer Blog on July 24, 2009 (boomark / email).