As a patient with severe obstructive sleep apnea, and a history of heart failure, I had learned the value of communicating early and often with my medical providers. When I noticed my sleep quality degrading, despite being a compliant CPAP user, I contacted my primary care physician. My doctor ordered what I had always known as a basic test, namely, an in-lab sleep study to evaluate the issue and to understand what pressure the doctor would order the machine to be set to.
When my insurance company denied my test as "not medically necessary" I was certain that it was just a misunderstanding, lack of documentation, or some other administrative issue that would be corrected. When my doctor's office tried to resolve this and no progress was made, I began to get concerned. My concern turned to disgust as I quickly realized that my insurance company was denying coverage despite the fact I clearly met their parameters and requirements for the test.
I was truly facing a large, unorganized, machine of an insurance company that I felt did not value my health, my policy, or the fact that my hard work pays for the policy that was issued. They denied my doctors legitimate order for testing repeatedly, and processed my appeals without any genuine concern for my health and welfare. Unlike the Department of Insurance, when my insurance company "reviewed' my case data, they did not even look at all of the available healthcare records that were in their possession. It was clear that my insurance company was hopelessly lost in understanding me as a patient and rather only saw me as a liability.
The Independent Medical Review (IMR) process was an amazing act of professionalism in my experience. Submitting the case for review was straightforward, and the Department of Insurance communicated with me about the status of my review in a very timely fashion. I was able to submit supporting documentation, as was My insurance company, who submitted their own policies and procedures as well as their various denials. The Department of Insurance had an appropriate resource trained in the area of medicine that was at issue in my case review the relevant documents. When I read the summary from the reviewer, I felt an enormous burden lift, because I realized that finally somebody was listening who was clearly motivated by a positive health care outcome.
The decision to direct my insurer to provide the coverage I was entitled has directly led to me being able to be successfully treated. To me, this means quality of life, and the ability to work so that I can provide for my family. My insurance company was shortsighted and treated me like a number. The Department of Insurance treated me like a human, with dignity, and has empowered me to restore my health!
My wife and children would like to thank everyone at the California Department of Insurance. Obviously for me, being healthy is important. My family means everything to me, and if my insurance company had their way, I am not sure I would be in the best place to take care of them.
Thank you does not convey it well enough.
- Tony S.
(Email received February 3, 2014)