Case Studies

In January of this year, Mr. R. called us for assistance with an appeal to his HMO for denial of service. He was diagnosed with pancreatic cancer, and his HMO doctors gave him six months to live. In the meantime, he found an out-of-network specialist at UCLA who told him his tumor was operable and the surgery could extend, or possibly save his life. His HMO refused to pay for the surgery – as no doctor in the HMO could perform it – and they would not authorize a referral to the UCLA specialist. We helped Mr. R. appeal the initial denial and, after two months, he received a favorable decision in his appeal. At that time, however, it was discovered that his tumor had grown too large for successful surgery due to the delay in the appeal decision.

Mr. R. went back to the UCLA specialist and received chemotherapy for two months to shrink the tumor for possible surgery. After his tumor was sufficiently reduced, the specialist recommended surgery for him again. Mr. R.’s HMO once again denied the procedure. HICAP helped Mr. R. file an expedited appeal, which was again decided favorably for him. He received the surgery this time, which was a success, and Mr. R. is on the road to recovery. Mr. R. also realized a savings of $140,000, which he would have had to pay out of his own pocket for the surgery had he not won the appeal.

Although not all of our clients have such urgent needs, we can happily report that we are able to resolve most of the issues and concerns about their health insurance coverage. If you have a question about your Medicare or related health insurance, be sure to call HICAP at (800) 434-0222.