An Owings Mills, Maryland woman (Jen) suffered a traumatic brain injury in October 2015 after she was thrown from an all-terrain vehicle (ATV) while in Costa Rico celebrating her 40th birthday with her husband (Brian). A month later, Jen was medevac’d to Baltimore for treatment and to emerge from a drug-induced coma. She is now at a rehabilitation center getting physical, occupational and speech therapy nearly every day.
Although baby steps, Jen’s family and doctors say she is making progress. Brian said she is more alert and will squeeze his hand on command. Doctors still aren’t sure how long recovery will take or what the outcome will be, but Brian said Jen is strong and has a lot of fight in her.
The community has rallied around to help Brian and the couple’s three young children, whether it be through financial support, food, or prayers. Their insurance company, CareFirst, seemed to be there for Jen, too. That was until last month when the couple received abrupt notice that the insurer was cutting Jen off completely.
Brian gathered 13 months of medical records and letters from Jen’s doctors and filed an appeal. It was quickly denied. Brian said the denial letter addressed several inaccuracies. CareFirst said that Jen had a spinal cord injury, but she does not. They said she was breathing with a trach, but Brian said that Jen has not used a trach in eight or nine months. The insurer said Jen couldn’t track with her eyes, but Brian said she can and does on a daily basis.
When the news media contacted CareFirst about the denial, the insurer sent this reply:
“CareFirst is aware of Jen’s case and provided coverage for her medically necessary care for the past year. In accordance with our medical policy, and corroborated by independent medical review organizations, we have determined that her care is now custodial and therefore not covered under the terms of her contract.”
Jen’s doctors said that they believe she can improve, but cases like hers can take months to years of recovery, a time-frame insurance companies don’t want to recognize. Her doctors believe if Jen’s care is completely stopped, it is unlikely she will regain functional communication.
Brian said he is not giving up and will appeal to the Maryland Insurance Commission. In the meantime, without benefits, he is forced to tap into the family’s own assets for Jen’s therapy at a rate of $25,000 to $30,000 a month. Once those assets are depleted, what happens? Ultimately, Jen will be forced to seek government assistance.
Why is CareFirst playing with Jen’s health, indeed, playing with the quality of her life? Because they can; only a judge or jury can make them do the right thing here. CareFirst happily took this couple’s premiums for years. Jen and Brian paid them with the expectation that, when or if the time came, CareFirst would honor the policy’s promise to pay the benefits. Please keep in mind that the majority of insurance premiums paid do not get paid out in benefits. Despite this, these insurance tactics are not uncommon; they reflect insurance attitudes nationwide. The main concerns of insurance companies are “profits” and “shareholders”. Need more examples? How about the terminally ill California woman we recently wrote about who was denied treatment to extend her fight for life, but who could get a drug to help end her life? Insurance companies love to cash premium checks; most people pay premiums religiously, without ever filing a serious claim. Yet, despite a sterling record of on-time premium payments, insurance companies continue to withhold coverage to those who need it and paid for it, for decades.
People rely on health insurance as a safety net in time of crisis. The very idea of insurance is that the insurance companies promise to pay for costs associated with medical illnesses or emergencies. When you file an insurance claim, by law, the insurance company owes you a duty to act in “good faith.” Good faith does not mean finding clever ways to avoid the obligation to pay a claim. Yet, insurance companies are notorious for raising premiums, denying claims, and refusing to cover those people who need coverage the most. They want your business (and your money for premium payment purposes), but when you need the assistance that you paid for, when you need them to pay for treatment, they deny the claim. Keep in mind that these claims decisions are made by claims adjusters, not doctors or nurses. They have no medical training and advance with the company by controlling payouts to policy holders. And, when you do make a claim and the company pays it, your premiums often increase. What other product or service penalizes you for using it exactly the way you are supposed to?
We need to decide whether insurance is a right or a privilege. We need to put human life above dollars. The path for CareFirst is to find grounds for claims approval rather than seek a clever “out” to deny coverage. Does this company really put “care first” or are profits their number one goal? Lawsuit Financial says: Pay the claim, CareFirst; help this unfortunate woman get better. Do the right thing here. What do you think?
Mark Bello is the CEO and General Counsel of Lawsuit Financial Corporation, a pro-justice lawsuit funding company.
Attorney, certified civil mediator, and award-winning author of the Zachary Blake Betrayal Series. Mark Bello is also a member of the State Bar of Michigan, a sustaining member of the Michigan Association for Justice, and a member of the American Association for Justice.