November 24, 2014; Daily Beast
It is terribly difficult to read this article from Malcolm MacDougall about the lack of help his health insurance company delivered during his recent bout with prostate cancer. It’s because MacDougall is dead. Knowing he was going to die, he wrote this article from his Lenox Hill Hospital bed five days before he passed away.
MacDougall received a diagnosis of stage-four metastasized prostate cancer. According to what he wrote, his insurer, Health Republic of New York, and its affiliate, MagnaCare, refused to pay his medical bills for the five months that followed. A nurse from Health Republic overruled the diagnosis of his primary care doctor and determined that a test to document the progress of the cancer was unnecessary. Five months later, three doctors overruled the nurse’s oncological decision and he was admitted to Lenox Hill for a battery of emergency tests and treatments. It was too late.
As he lay in the hospital bed, he wrote that after five months, Health Republic determined that his doctors were not “in network” and therefore his expensive cancer treatment bills wouldn’t be paid. Although his insurance broker confirmed that his primary care doctor actually was in network, apparently MacDougall had used the wrong code—one digit off—and so Health Republic ruled his medical costs ineligible. Explanations from Health Republic as to why it took five months to finally reverse itself and cover his costs were unforthcoming. Health Republic, as well as his insurance broker, blamed the doctors; the doctors blamed the insurance company.
“It seems every step you take leads to yet another maze,” MacDougall wrote. “So far, I am out a good deal of money. More importantly, I had to postpone doctor visits and treatments while I tried to untangle the mess. One of those treatments postponed was for injections designed to strengthen bones against further cancer spread. Missing those injections might well have worsened the serious problems I’ve had to confront.”
When he finally found a new oncologist who was “in network,” who then ordered a CAT scan that he had postponed for more than a month and a half, Health Republic refused to pay for the test, with a Health Republic nurse overruling the oncologist. In desperate pain, MacDougall was finally admitted to Lenox Hill and given the CAT scan, which showed that the cancer had spread from his rib to next to his spine, which he wrote was “a worst-case scenario.” Rather than paying, Health Republic allowed MacDougall to file a grievance claim with backup documentation, but five days before his death, he wrote that they had not acknowledged receipt of the claim, much less called to discuss the specifics.
Sign up for our free newsletter
Subscribe to the NPQ to have our top stories delivered directly to your inbox.
“I am not holding my breath,” MacDougall wrote.
In his last communication from Health Republic, which refused to approve his cancer tests, the company noted that MacDougall, the patient, was over 85 and had been a smoker. “So, that’s it. According to my insurers, I have already lived too long,” MacDougall concluded. “And because, until recently, I enjoyed my two or three cigarettes a day, I am a bad boy who is not worth the cost of keeping alive. No wonder they won’t pay.” The company’s denial was a form letter.
Health Republic provided an explanation to the Daily Beast that the company “reviews coverage requests to determine if service is covered under the member’s plan…[and] ensure(s) that service is delivered within established evidence-based clinical guidelines issued by recognized national authorities. Our reviews are conducted by highly trained clinicians.” Prevented by HIPAA, Health Republic did not comment on the specifics of MacDougall’s treatment.
Why write about this here? Because Health Republic of New York is a nonprofit, one of the nonprofit consumer health insurance co-ops that NPQ has written about as a step up from the big corporate behemoths that dominated the health insurance industry prior to the Affordable Care Act. The nonprofit’s tagline is, “we are for people, not profit.”
Having watched the consumer cooperatives, we suspect that MacDougall might not have been able to navigate the Kafkaesque world of big insurance companies any better than he did Health Republic’s. Both Health Republic and its mammoth competitor, Empire Blue Cross Blue Shield, have garnered criticism in the past year from consumers and from Attorney General Eric Schneiderman, including issues of delayed approvals and payments for patients. Perhaps MacDougall might have been able to get some help from a consumer-oriented ombudsman, but it appears that the consumer assistance programs created in New York, all important, tend to focus on helping people get and maintain insurance coverage, not necessarily on intervening if the insurers aren’t delivering as the consumer thought they would or should, though the Community Health Advocates program of the Community Service Society of New York provides instructional materials to help patients deal with out-of-network billing issues. The website of the New York State Department of Health offers a panoply of health programs and access to third-party navigators for picking insurance and evaluating plans, but a patient’s resource to intervene in a situation like MacDougall’s doesn’t seem to exist—or if it does, it isn’t easy to find.
Operational only in 2013, Health Republic may be nearly as flummoxed as MacDougall was in terms of sorting out what was happening during his illness, except that Health Republic lives on while MacDougall has passed away. The reality for MacDougall and for the nonprofit health insurance cooperatives is that they both had to function in a health insurance climate that demanded operations as a business—regardless of the fact that Health Republic is a nonprofit. Until this country comes to see healthcare as a right for all, regardless of the cost and paid for by government, as opposed to a business decision to be made by insurance providers, there will be more incredibly sad stories like MacDougall’s.—Rick Cohen