Mary and Annie

To contextualize the claims procedure for health insurance cases, you may refer to the stories of Mary and Annie. We will also watch excerpts from Sicko, Michael Moore's 2007 documentary on the U.S. healthcare industry.

Mary
Mary is a twenty-something attorney, recent DePaul Law graduate who is employed by a Big Law firm. Mary had stage three brain tumors. She had the largest of the tumors removed and is undergoing treatment to kill the remaining tumor and eradicate any residual cancer cells. You may read about her story on her blog, listed under Resources. Her first post describes better and in greater detail, her prognosis and initial treatment. Currently, Mary is undergoing experimental treatment at the Mayo Clinic in Minnesota. While Mary has not posted about any issues with her health insurance company, one may find several potential issues among the episodes recorded in her postings, among them her election to have a CAT scan (Was it pre-approved?)and her experimental cancer treatment. Please read Mary's initial blog posting and reflect on ERISA health plan claims procedures that may arise.

Annie
Annie had a menisectomy during her first semester of law school. In her case, cartilage was cut from her right knee. She had a bucket tear in the cartilage. It had torn in a flap that sometimes hung down like the handle of a bucket. The tear caused mechanical problems: Annie was sometimes unable to get up from a seated position and her leg sometimes locked when she walked. Because of the mechanical problems, the doctor felt that immediate surgery was needed to avoid permanent damage. The doctor was the number one recommended surgeon by her student health insurer, Aetna. After her surgery, Aetna refused to pay for much of the surgical costs. For example, Aetna claimed that the surgeon used non-plan-approved assistant doctors, nurses, and facilities. Annie was billed in full for all of these costs.

Annie's surgeon then announced that he did not believe in physical therapy. Aetna deferred to his medical expertise. Other plan doctors refused to overrule the surgeon. In her right leg, Annie developed a rope-like knotted illiotibial band (IT band), and cramping in the calf and quadriceps. Her surgeon still refused to prescribe physical therapy. Eventually, one of her law school's parent institution's sports doctors (a physician for the basketball and soccer teams) examined her and prescribed physical therapy. Annie's physical therapist told her that her surgeon had previously worked with him, but that the surgeon was now paid bonuses by insurance companies whenever he did not refer patients to physical therapy.

Annie spent a lot of time corresponding with Aetna by mail and telephone.
Reflect on the ERISA health plan claims procedures that apply to Annie's case.