The Tenacious Gumptionista

Have you ever wanted to fight a corporation, but didn’t think you could win so you said the heck with it? Well, I am living proof that if you are persistent, patient, and you plead a logical case, you will prevail. I hope this story convinces you that you can fight and win, and be the tenacious gumptionista you were born to be!

In 2005, I had a bilateral reduction mammaplasty surgery. Basically, I came out of the womb a DD-cup, and it was starting to impede on my life. There were certain pre-surgery criteria I had to meet in order for the surgery to be covered by insurance: height/weight requirements, a letter from my doctor and chiropractor indicating the need for the surgery, and the insurance company needed to see a photograph of my naked chest (still not sure to this day why that was necessary, but grateful the pictures haven’t resurfaced on the Internet). A few weeks later, I received an acceptance letter from the insurance company. They said that there was, however, one more piece of criteria that had to be met post-surgery. Insurance required that a certain amount of tissue be removed. My doctor explained to me that if he removed the amount of tissue that they requested, I would be disproportionate. With that being said, I authorized my surgeon to make his best judgment, and I would take on the insurance company later. While I was recuperating, I decided that there was no better time than the present to send a letter to the insurance company. I sent the following to the President and CEO of the health insurance company:

“The problem I am about to state has not arisen yet, however, I fully expect it to present itself in the very near future. I had mammaplasty surgery one week ago, and although you pre-approved the surgery, the amount of tissue removed was less than the allowable. Although I have not yet received a rejected claim, the fact that the insurance company was adamant that the claim rely on the amount of tissue removed, I fully expect to receive the rejected claim any day now. I feel a great relief from the surgery, so I am not sure why the amount of tissue removed should be determined by the insurance company. Shouldn’t you base it on how the patient feels? Do you think a woman would go through the emotional and physical pain of having surgery if they didn’t have to? This is a major surgery, and no surgery is deemed reasonable unless it is going to help you physically. I am not the type of person to just go away. I am relentless and will continue to fight this for other women, and change the insurance policies, law, etc.”

As fully expected, I received a letter three weeks later rejecting the claim because “the surgeon removed less than the amount of tissue that was authorized.” I then sent another certified letter to the CEO and President of the insurance company.

“I sent a letter to you on 8/25/05, which addressed a recent mammaplasty surgery, and the fact that the claim would most likely be denied. In December, I received a letter from indicating that, in fact, the claim had been denied. Just as I had stated in my letter to you, the amount of tissue which was considered “allowable” was not removed. I further explained that the surgery had changed my life, despite that the “allowable” amount was not removed. I understand that insurance companies need to have some standards for approving and rejecting claims however, this is ridiculous. For you to make a determination on how much tissue needs to be removed to make me feel better, is unacceptable. I trusted my surgeon to make the right decision. He is the person that should determine what will relieve my pain. I will continue to fight this and will be going to the medical board to change this approval process for other women. I would appreciate a response, as I would hope you are taking your subscriber complaints seriously. We are the backbone to your business, and do have a say in how our employers choose their providers.”

In February 2006, I received another letter denying my claim. Now the insurance company was indicating that “the services have been determined to be cosmetic and not medically necessary.” Interesting how they have now completely changed the reason for the denial. At the end of the letter it said that I had the right to request an Independent Medical Review (IMR) through the Department of Managed Health Care (DMHC). The fight has now just begun!

I went to the website and downloaded the IMR application. In the application, I said that the issue is not with the claim being denied, it is with the way criteria is established for these surgeries. Three weeks later, I received a response from the Center for Health Dispute Resolution. The CHDR is under contract to perform an independent medical review. They employ doctors and health care professionals who study the case file and medical records to decide if the claim is medically necessary. The report said, “the patient underwent the procedure to relieve her documented symptoms. It was therefore medically appropriate and indicated. The patient indicates that her symptoms were relieved by the procedure. That a smaller amount of tissue than authorized volume was removed does not negate the necessity of the procedure, and as such, the health plan’s denial should be overturned.” Hallelujah, Hallelujah, Hallelujah!!! Am I dreaming? Did a doctor of sound mind really say that I was right? Within two weeks, I received an 80% reimbursement.

The key to fighting a corporation is:

• Document the situation. As soon as you realize there may be an issue, be sure to document everything including names of individuals you spoke to, the dates of the phone calls, and dates and copies of all correspondence.
• Certified letter to CEO. Send correspondence, certified, to the President or CEO of the company. You will always receive a response.
• Clear and concise correspondence. In your correspondence, be clear and concise. Ask for what you want and always include the fact that what has happened is “unacceptable.” I am not sure why that word has so much power, but it does.
• Consequences. Include a consequence if the issue is big enough, and be prepared to follow-through. In some situations, I have said that I will contact the State Medical Board, consumer advocacy agency, or an attorney.
• Be reasonable. If you truly believe in your heart that what you are asking for is reasonable, then it probably is. If you are writing to an airline because you had a bad experience, but you are asking for two first class tickets around the world, you are setting yourself up for rejection.
• Give them a timeframe. If you expect to hear back from someone within 5 business days, let them know that. Indicate what will happen if you don’t hear back from them in the timeframe you requested.
• Documented back-up. Always request that they get back to you in writing. This way you will always have backup.
• Be patient, but persistent. Companies have all the time in the world to continue to deny your issue/claim. It doesn’t matter to them if they fight you for a year.
• Stick to your guns. Stay on top of it until you get the response you want, and only accept no, if you can live with it. If you no longer have the energy to fight, then it’s time to stop. Remember though, it may only take one more letter to resolve in your favor.