PacifiCare and HEALTHY ROADS fight update.

So here's the latest in my fight with the Insurer, PacifiCare.

1) They're forcing me to do a six month program, delaying my access to the national kidney transplant list.

2) I hired Walter Lindstrom of ObesityLaw.com; On August 10, I received a copy of the 12 page letter sent to both PacifiCare and the Department of Managed Health Care;

3) I'm reading through the letter, and it's everything I said, with the added emphasis of coming from a lawyer who has won many cases against this company; AND the government agency, the DMHC has scared my HMO into doing the right thing several times before. (Yay).

So now, the second appeal has been filed, and we'll sit back and wait; I have been instructed NOT to talk to PacifiCare, and to politely refer them to my counsel of record (eg, Walter).

Keep me in your thoughts, and prayers, kids! Here's to the loser bench being 1 step closer.

I am so sorry for what you are having to go through! I will keep you in my prayers!  Karen

Thank you, Karen. I'm confident that this is going to work. I was denied once, and my motion for an expedited appeal was denied, so that's why I called in a lawyer. :)

I hope everything works out Meg. Hang in there Kim.

I'm hanging! :D

Meg,  I will be right behind you doing appeals and going to DMHC. My M.D. just submited the request for authorization for me to see the surgeon. I am just waiting for their letter telling me I have to do the Healthy Roads diet to fire off my first appeal. I am doing a rough draft so I just need to tidey it up when the letter from Pacificare arrives and put it in the mail.  Keep us updated. Kim B.

If you HAVE to hire a lawyer, Walter Lindstrom at ObesityLaw.com has won against PacifiCare and they have good contacts at DMHC. Their fees are about $450-$850. It's really not bad.  It became much less of a headache and less tears were shed after I hired them. :) It's just a waiting game.

Meg, Thanks for the info. I was wondering about the cost of a lawyer. I think it would cost less for me to just change from Pacificare HMO to Blue Cross PPO starting Jan 1st. I would then have a 500.00 deductible and they would then pay 80% and would be much less hastle. Several people at my job have had the surgery done with Blue Cross and it is much easier. I will not be able to change until open enrollment in Dec. though and by that time I could be done with the 6 month diet and Pacificare would then pay in full for the surgery. Also, it is possible my work may decide to drop Pacificare in Jan. and go with another HMO for us.  We have a choice of the Blue Cross PPO or Pacificare HMO (Pacificare this year and last year we had Healthnet HMO). So, it is possible I would finish the 6 month diet right about the time my work decides to switch to another HMO!  Is'nt that great! (not). That is one reason I would really like to fight the 6 month diet thing and get on with this in the next 4 months or so. I am going to try the appeals. There are lots of ways this could play out for me and only time will tell. Life is such an adventure!!! Again, thanks for the info. Kim B.

For what it's worth, I'm 4 months into the HealthyRoads program with Pacificare Insurance.  I thought about fighting it but only learned you could after I was a little over a month into the system.  My counselor promises me we can begin the pre-surgery stuff 4 months into the program to be prepared to have surgery right away as soon as the 6 months is up.  She says I am doing everything being asked of me in this program and I laugh because I already know more about bariatric surgery than she does!  LOL  She states the goal of the 6-month program is to get a person in as healthy a condition as they can be before going into surgery.  I don't know about that but that's what she says. Good luck to everyone who is battling insurance approval.  I am still reserved in this that Pacificare might come up with some other excuse to not approve the surgery for me even after doing the required HealthRoads program.  That's when I'll be ready for a real fight, if that happens! Kathi

I understand that, and if it wasn't an issue of life-saving, I probably wouldn't fight it. The problem is that I CANNOT get listed with the kidney transplant list UNTIL I have a surgery date; this means every DAY that I'm delayed in surgery, I'm not getting any wait time on the transplant list. I am enrolled in HR, but I'm still fighting it.