I have been dealing with a wrist-tendon injury for well over a year now. They have done 3 surgeries now. Working with the insurance company has been a living hell, and for awhile it seemed to have gotten better. This last surgery was to be the final surgery (they replaced one of the bones with a metal piece & fused some other bones together - they called it the 3-c surgery). The plan of action was to do the surgery & then several months of physical therapy BECAUSE I would have very limited flexability/movement of my hand. I was told that the pain would go away in time, & although i would not have complete flexability of my hand I would have some (right now it stays stationary & can only move my fingers - I have to use my other hand to flex the hand).
The fucking insurance company decided not to approve the physical therapy. So now, I am “stuck” with a barely usuable hand. Yes, I do my home therapy & the SO helps me with my stretches - which, btw, HURTS LIKE HELL! It pisses me off the most because the goal was to get me back to work ASAP. Without the proper therapy - how does the insurance company expect me to accomplish this?
I received the call from the therapy clinic that the insurance denied the therapy per the discussion between the insurance doctor and my doctor. If this is the same fucking doctor I had to deal with earlier with the onset of my injury that doctor needs to have his head examined! Example - in non-med terms the doc basically indicated that I was nothing more than a drug addict attempting to make up an injury to gain access to pain meds. Fortunately, with the help of a third party assistant, I was able to prove otherwise (and with the help of my hand doctor) & won my case. Unfortunately, with the delays, my hand only got worse with time. This was the final and most drastic option - other than cutting off my own hand, which I have half-jokingly threatened.
So now what do I do? I havent been able to work because of the injury, but i s’pose now that I dont have to worry about making time to go to therapy sessions I shouldnt have a problem finding a job (I actually have one waiting for me once the dr releases me) - but what are the chances of KEEPING the job with the physical disability of my hand? My hand tires easily from typing & it hurts (the tendons pull and ache & will at times shoot up to my neck). Contrary to what some believe, I do not sit around and play games all day - this is not true or physically possible for me. And what I do play, doesnt really require me to use both hands - i have a keyboard that has one-key macro activation which cuts back a lot on keystroke. A lot of times when i am on - I am usually fishing or crafting. I use my right hand for basically everything. Even most of the typing. If I aply for an office job and there’s a typing test - forget it, my typing speed is below pretty much all company standards. I cant lift anything - can barely hold a cup of coffee! Gripping anything is extremely difficult to do - turning on a lamp is even a challange with this sorry ass hand of mine.
What the fuck happened to getting me as close to “normal” as possible? What am i supposed to do if I am unable to do something because of my wrist and I therefore am jeopardizing my employment? Damn asshole doctor fuckwad.
I’m so angry I could spit fire. :mad: And profanity.
Insurance doctors are there to make sure that some doctor-for-hire working out of a U-Haul garage doesn’t refer you to unnecessary treatments to pad his and his colleagues’ fees on the back of the insurance company, whose job is not to pay to make you perfect but to underwrite the cost of making you functional.
If this is not the case with you, then you should follow your insurance company’s appeals process, get an evaluation by a third physician, or file suit to enforce the same.
If you don’t want to go to the trouble to prove your injury, or if this IS the case with you, then by all means vent away.
But don’t operate on the premise that an insurance company has the duty to throw money at you and scream at them when they don’t.
The company made an actuarial determination. If that determination is not reflective of your personal situation, bring this to their attention and get a more thorough investigation.
I understand the abuse of medical procedures by doctors and patients - especially when it comes to padding wallets. The situation here is that my left hand is NOT FUNCTIONAL. I cannot bend it on my own, I can barely lift a half empty plastic bottle of soda with that hand. When I do my stretches and home therapy it hurts - I’m talkin severe ongoing pain. So part of the therapy’s purpose is to learn to minimize the pain and gain mobility.
I’m venting because I have to go through this AGAIN. I had to prove to them that there really was something wrong with my hand and I was not making it up (or did you miss that statement that the insurance company’s review doctor indicated I was a drug addict & making it up?). Yes, I understand that the review doctor only has the reports to look over and not examine the patient, but in the report, the doctor who did the initial testing indicated that the diagnosis was not correct and there is definately a physical problem.
So now it starts again…it is stressful. Extremely stressful & something I’m not looking forward to. And for the record - I’m not on any pain meds besides Tylenol/Advil so there is no pain-med addiction (though there are times I wish I was!).
HSHP is right. It sucks, and look for the kind of thing you are going through to get a LOT more widespread if the leftists ever get their way and force socialized medicine down our throats, but please follow the appeals process, it usually (sadly not always) gets the right thing done. Also remember that the Insurance Commissioner for your state can be a powerful advocate on your side, if your insurance company seems to be dragging their feet responding to you contact him/her, S/he can help.
I think that HSHP is working on the assumption that Pixilated can pay for the PT and then get reimbursed after the situation plays itself out. This is sometimes true, and you can sometimes even get the doctors to defer some or all of the payment in this situation, but it is by no means universal.
But the system is designed to catch as many people gaming the system as possible, and it does so reasonably well. Sometimes, however, the world being imperfect, a dolphin gets caught up with the tuna.
The problem then is convincing the fisherman that you are, indeed, a dolphin.
And yes, the burden is on you to prove that. You have more ability to do so.
Litigation as a last resort either gets satisfaction, forces a settlement, or forces a cost-benefit decision where you could just get paid anyway, but these are all steps you just have to take.
The insurance company doesn’t throw money at anyone who says “ouch,” and, while I do recognize that your situation is not that clear, you get the idea.
My heart goes out to you and I wish you the best.
**
HSHP,** former health plan administrator.
Funny, an oft-lauded benefit of socialized medicine—at least the way it’s practiced in countries far less enlightened than ours—is that patients are not arbitrarily turned down for procedures, or required to fight for approval from a faceless health care organization that controls all the purse strings and has a vested interest in refusing service to as many of its customers as it can.
I admit, though, I haven’t read the evil leftists’ prospectus for a socialized U.S. health care system. Perhaps you could forward that to me?
Insurance company is in business to make money. Making him whole is not in their interest. Fighting as many costs and denying as many services as possible helps the bottom line.To expect more from an insurance company is a joke.
You have to fight and threaten to sue and procedurally fight them. Then you have a chance.
I had ankle surgery about a year ago, and my surgeon told me that I needed to make sure I had PT after. That boss would allow the time off, my insurance would approve it, and that I could/would pay for it on my own if they didn’t. If I didn’t agree to this, he wouldn’t to the surgery, because otherwise I’d never walk right (and unaided) again. Fight for your PT-- it’s important.
I had heard so many horror stories that I was far more afraid of the insurance company than I was of the operation. (They paid every single bill with not a peep of complaint and within 30 days, btw. People don’t believe me when I tell them this.)
My parents insurance company (Aetna) seems to deny thing out of hat, but my Mom has a had a lot of luck with appeals and getting them to pay after all.
I don’t know if all states have Insurance Commissioners, but mine does. A friend contacted his office when her insurance company paid for only half of a series of prescribed treatments, stating that additional treatments were superfluous.
Within a month of contacting him, the matter was settled and the insurance company was required to pay for the remaining treatments. Evidently, the whole process was rather painless considering it had to go through a government office.
You know, I understand that they don’t want people taking advantage of the system. But why in the bloody blue fucking hell would they approve the surgery, but not the therapy afterwards? As a casual reader, that doesn’t make any sense to me.
My thought exactly - but the insurance would only accept the recommendations from the doctor in 2 seperate requests (I was unaware of this). Had the doctor had any concern that therapy was to be denied, it would have been brought to the table BEFORE I decided to have the surgery. The insurance company’s decision to deny therapy after the surgery is inconceivable because without it my hand is merely there for decorative purposes.
Looks like my Dr got some therapy approved - and he wasnt happy cuz I am now behind schedule (I was supposed to have the first set done at the end of this week). Oh well, what matters is that I am now therapy-approved!!
PS The letter indicated that it had been denied because it was missing some basic information such as date of injury, date of surgery, etc - that was all included on the first page which the insurance did not get. You would think it wouldve been easier to call the dr office and tell them/ask them for the missing page vs typing out a denial letter & mailing out 3 copies (me, dr office, & therapy clinic). Imagine the time it would have saved.
Congrats! Since it was such a hassle in the first place, I hope you take your PT to the fullest advantage. I know more than one person who wishes they hadn’t puttered out on their PT!
